Method, system, and computer program product for physician efficiency measurement and patient health risk stratification

[0001] This application claims priority from provisional application Ser. No. 60/549,601, filed Mar. 2, 2004.

[0002] 1. Field of the Invention

[0003] The present invention relates broadly to management of medical information. More specifically, the present invention relates to management of medical information to perform and report measurements of physician efficiency.

[0004] 2. Description of the Prior Art

[0005] Recent evidence has suggested that about 10-20% of physicians, across specialty types, practice inefficiently. Efficient means using the appropriate amount of medical resources to treat a medical condition and achieve a desired health outcome. Thus, efficiency is a function of unit price, volume of service, intensity of service, and quality of service. This group of inefficient physicians is responsible for driving 10% to 20% of the unnecessary, excess medical expenditures incurred by employers and other healthcare purchasers, equating to billions of dollars nationally.

[0006] To improve market efficiency, it is useful to apply a system that accurately measures individual physician efficiency. Recent evidence has demonstrated that leading physician efficiency measurement systems have only about 15-30% agreement across measurement systems. This means that when one system ranks a physician as inefficient, only about 15-30% of the other systems ranked the same physician as inefficient. The remaining 70% (or more) of systems ranked the same physician as efficient.

[0007] These findings show that existing systems have significant error in attempting to accurately identify inefficient physicians. The error needs to be eliminated, or significantly reduced, if healthcare purchasers are to accurately identify inefficient physicians and take action (e.g., attempt to change physician behavior, provide incentives for employees to use more efficient physicians). Every physician falsely measured as efficient (or inefficient) leads to continued inefficiency in the healthcare marketplace.

[0008] There are ten common physician (or physician group) efficiency measurement errors present in most existing physician efficiency measurement systems, which are in order of importance: (1) examine all episodes of care for a physician; (2) use a physician's actual episode composition; (3) no severity-of-illness measure by medical condition; (4) no identification of different episode treatment stages; (5) no age category assignment by medical condition; (6) no tracking mechanism for related complication episodes; (7) improper episode outlier criteria; (8) under-report charges attributed to partial episodes; (8) over-report charges attributed to episode endpoints; and (10) no minimum number of episodes of care. These errors are discussed next.

[0009] Many physician efficiency methodologies continue to examine “services per 1,000 members” or “all episodes of care” tracked to a physician. These approaches probably add the most to efficiency measurement error. The methodologies attempt to adjust services per 1,000 members and to adjust all episodes of care by age and gender—and then compare one physician's utilization pattern to a peer group average. However, age and gender explain less than 5% of the variance in a patient's medical expenditures. This means that over 95% of the variance is unexplained, and may be attributed to differences in patient health status.

[0010] Some methodologies adjust services per 1,000 members and adjust all episodes of care based on specific International Clinical Modification of Diseases ninth edition (ICD.9) code algorithms that measure expected resource intensity. The idea is that a patient's diagnosis codes will provide more predictive power than age and gender alone. The most predictive of the published and marketed models explain only 20% to 30% of the variance in a patient's medical expenditures. This means that 70% or more of the variance continues to be unexplained, and may be attributed to differences in patient health status.

[0011] Physicians often criticize the services per 1,000 members and the all episodes of care methodologies that use a predictive case-mix adjustment factor. Physicians state that the methodologies do not appropriately adjust for differences in patient health status—rightly stating that their patients may be “sicker.”

[0012] If all claim line items (CLIs) or episodes of care tracked to a physician are used in the efficiency analysis, then up to 70% of the observed utilization difference between physicians may be attributed to patient health status differences. Therefore, patient health status differences are measured rather than individual physician efficiency differences. This weakness in current case-mix adjustment tools means that not all CLIs or patient episodes of care treated by a physician can be examined. Instead, an isolated set of more prevalent medical conditions by severity-of-illness level needs to be examined across physicians of a similar specialty type.

[0013] The second measurement error, which occurs in most if not all current efficiency measurement systems, occurs when the physician's actual episode composition is used. The reason is as follows. The differences in physicians' patient case-mix composition results in differences in variability (i.e., the standard deviation) around a physician's average episode treatment charges. This variability is not due to the efficiency or inefficiency of a physician, but instead results because longer and more resource-intensive medical conditions generally require more services and, therefore, have more potential variability around average (or mean) episode treatment charges.

[0014] For example, easier-to-treat upper respiratory infection (URI) episodes may have the following mean and standard deviation (with outlier episodes removed): $185±$65. Here, the standard deviation around the mean is not large—and is 0.35 the size of the mean (i.e., 65/185=0.35). However, easier-to-treat pediatric asthma episodes may have the following mean and standard deviation (with outlier episodes removed): $1,650±$850. Here, the standard deviation around the mean is larger than for URI episodes—and is 0.52 the size of the mean (i.e., 850/1,650=0.52).

[0015] The variation difference between the two conditions is 49% greater for asthma than URIs_[(0.52−0.35)/0.35]. This variation difference occurs for two reasons: (1) more resource-intensive conditions require more services to treat; and (2) there generally are a small number of episodes available to examine in a given physician efficiency study as compared to the universe of episodes that could actually be studied—and a smaller number of episodes results in a higher chance for variability around the mean. This variation is not the result of physician treatment pattern differences.

[0016] If the statistically based variability around the mean is not corrected, then substantial error may enter into the physician efficiency measurement equation. Consequently, the final physician efficiency score differences may be attributed to the statistical condition-specific variability around the mean episode charge (due to the case-mix of episodes treated).

[0017] The above example showed that the variation difference may be 50% or more (around a condition-specific mean episode value). Logically, then, if all episodes treated by physicians are examined and efficiency scores are calculated, there has to be some statistical bias present.

[0018] A significant statistical bias may be present. Using a more traditional episode-based efficiency measurement methodology, lower-episode-volume physicians treating patients with a higher case-mix index score are more likely to receive an inefficient ranking as compared to lower-episode-volume physicians treating patients with a lower case-mix index score. This finding results because a physician with higher case-mix patients treats episodes having more variability (i.e., a greater standard deviation) around average episode treatment charges. With a low volume of episodes (most often the norm, and not the exception), this physician needs only a few higher-cost episodes then the peer group average to make his/her treatment pattern appear significantly higher than the peer group comparator.

[0019] However, a physician with lower case-mix patients treats episodes having less variability around average episode treatment charges. With a low volume of episodes, this physician's treatment pattern will not be as influenced by one or two higher-cost episodes as compared to the peer group average. Consequently, his/her treatment pattern does not appear (as often) significantly higher than the peer group comparator.

[0020] Thus, by examining all medical condition episodes, a substantial component of any observed physician efficiency difference may be attributed to statistical condition-specific variability around the mean episode charge—and not to physician treatment patterns efficiency. This effect may be present even when we examine the easier-to-treat episodes (SOI-1 level episodes) for the medical conditions.

[0021] The third error takes place in those efficiency measurement systems that do not employ an appropriate episode severity-of-illness measure. Severity-of-illness may be defined as the probability of loss of function due to a specific medical condition. Most, if not all, current claims-based episode groupers and methods do not have an appropriate severity-of-illness index by medical condition. Consequently, significant clinical heterogeneity remains in many episodes for a given medical condition. The end result may be physician efficiency differences that are attributed to inaccurate episode severity-of-illness adjustment, and not to physician treatment patterns variation.

[0022] Moreover, some claims-based episode groupers stratify formulated episodes for a medical condition by the presence or absence of a specific surgery or service (e.g., knee derangement with and without surgery; ischemic heart disease with and without heart catheterization). The reason for performing this stratification is to reduce episode heterogeneity for a medical condition. In effect, the stratification serves as a sort of severity-of-illness adjustment.

[0023] However, stratification based on the presence of surgery or a high-cost service results in at least two physician efficiency measurement errors: (1) performing surgery versus not performing surgery is the treatment patterns variation we need to examine in determining physician efficiency, and this variation is not captured in more traditional methodologies; and (2) the episodes of care are unnecessarily separated into smaller groups whereby physicians may not have enough episodes to examine in any one smaller group. Consequently, the stratified episodes of care need to be recombined for accurate physician efficiency measurement.

[0024] The fourth physician efficiency measurement error occurs in claims-based episode groupers do not have a method for identifying different episode treatment stages including initial, active, and follow-up treatment stages. Identifying different treatment stages is important in medical conditions, such as breast cancer, prostate cancer, colorectal cancer, acute myocardial infarction, and lymphoma. For example, breast cancer should be stratified into initial, active, and follow-up treatment stages.

[0025] An initial breast cancer episode is one where the patient has a surgery for the cancer (e.g., lumpectomy, modified radial mastectomy). An active breast cancer episode is one where no surgery is present, but chemotherapy or radiation treatment is observed within the episode. Here, the patient underwent surgery in a previous study period, so no surgical event is found in the patient's current ongoing breast cancer episode. Instead, during the study period, the claims data shows that the patient is being treated with chemotherapy and/or radiation. The presence of these treatments defines an active breast cancer episode. The utilization pattern and charges are different for an active breast cancer patient as compared to an initial breast cancer patient. A follow-up breast cancer episode is one where no surgery, chemotherapy, or radiation treatment is present in the patient's episode of care. After initial and active treatments, physicians will continue to code for breast cancer over the future years of patient follow-up care.

[0026] In a given study period, physicians do not treat an equal distribution of each episode type (initial, active, and follow-up). Moreover, the episode types have different average charges. About 20% of episodes may be classified as initial breast cancer episodes. Overall care for initial breast cancer episodes ranges between $15,000 and $25,000 per episode. About 15% of episodes may be classified as active breast cancer episodes. Overall care for active breast cancer episodes ranges between $12,000 and $18,000 per episode. About 65% of episodes may be classified as follow-up breast cancer episodes. Overall care for follow-up breast cancer episodes ranges between $350 and $600 per episode.

[0027] Consequently, the blending of the three treatment stage episodes results in average treatment charges of about $5,500 to $6,500 per episode. In fact, this is the average breast cancer charge that would be observed for most claims-based episode groupers.

[0028] The blending of initial, active, and follow-up episodes may lead to substantial physician efficiency measurement error. For example, assume during a study period that Oncologist A treats mostly active breast cancer patients, while some other oncologists have a good mixture of active and follow-up patients. Then, Oncologist A's treatment pattern for breast cancer will appear inefficient (as compared to his peer group of oncologists) because active episodes are about 30 times more expensive to treat than follow-up episodes. In fact, Oncologist A's treatment pattern difference is attributed to a different treatment stage episode case-mix.

[0029] Therefore, treatment stage episode types need to be correctly identified and separately examined. Otherwise, the final physician efficiency score differences may be attributed to nothing more than the initial, active, and follow-up episode case-mix.

[0030] The fifth error happens in those physician efficiency measurement systems that do not examine condition-specific episodes by age category. Studies have illustrated that broad-based age bands are important to separately examine—even after episodes have been assigned a severity-of-illness index. The reason is that physicians tend to treat children and adults differently for most conditions. For example, children are less likely than adults to receive a chest x-ray and potent antibiotics for many medical conditions. If episodes are not examined by broad-based age category, the end result may be physician efficiency differences that are attributed to patient age differences—and not to treatment patterns variation.

[0031] The sixth error occurs in those physician efficiency measurement systems that do not link and include the charges and utilization from a patient's complication episodes to his underlying medical condition. Complications are those episodes that are clinically related to the underlying medical condition. Consequently, many condition-specific episodes have under-reported charges. In fact, actual outputs from some claims-based episode groupers may show under-reported charges for patients with diabetes and other chronic conditions (e.g., asthma, congestive heart failure).

[0032] For example, the reason for the under-reported episode charges is that physicians code up to 70% of an average diabetic's charges under related complications to the diabetes (e.g., eye, neuropathies, circulatory, renal) and not diabetes care. Therefore, without considering and including related complication episodes with the actual diabetes episode, physician efficiency differences may be attributed to incomplete episode charges and utilization—and not to treatment pattern variations.

[0033] Furthermore, for patients with specific medical conditions, any model that attempts to stratify patients by health risk may produce unstable or erroneous results. The reason is that a patient is missing key claims information needed to accurately classify a patient into an appropriate severity-of-illness and other classes. For example, without tracking related complications to a diabetic patient, many diabetic patients will appear to have no complications when in fact they have eye or circulatory complications.

[0034] The seventh physician efficiency measurement error happens when the condition-specific outlier episode analysis is not performed in an appropriate manner. Many current methodologies perform the high-end outlier analysis by eliminating a percent of condition-specific episodes at the peer group (or aggregate episode) level. That is, the methodologies eliminate the high-end outliers before assigning episodes to physicians.

[0035] However, this method results in physician efficiency measurement error because a higher proportion of episodes assigned to the most inefficient physicians will be eliminated (as compared to the proportion of episodes eliminated for efficient physicians). Consequently, the inefficient physicians' condition-specific treatment patterns now more closely resemble the treatment patterns of the efficient physicians.

[0036] An example demonstrates this error. Assume Physician A has seven episodes of acute bronchitis with the following per episode charges: $235, $245, $325 $400, $525, $550, and $600. Also, the outlier cut-off threshold for high-end outlier episodes is set at $399 at the peer group level. Physician A now has only three episodes remaining at $235, $245, $325. The mean charge is $268 per episode. Assume Physician B also has 7 episodes of acute bronchitis with the following per episode charges: $210, $225, $235, $255, $285, $320, and $390. The peer-group level outlier threshold remains at $399. Therefore, Physician B has all seven episodes remaining, and the mean charge is $274.

[0037] The end result shows no statistical difference between Physicians A and B. The mean episode charge of Physician A is slightly lower than Physician B (i.e., $268 versus $274 per episode). However, using an outlier rule where we eliminate 5% of episodes (or at least 1 high-end outlier) are eliminated at the physician level, the results are significantly different. Physician A now has six remaining episodes (i.e., here we eliminate only 1 high-end outlier), and the mean charge of the six non-outlier episodes is now $380 per episode. For Physician B, the mean charge for the six non-outlier episodes is now $255 per episode. Physician A is statistically higher in average (or mean) episode charges than Physician B by $125 per episode.

[0038] The eighth error occurs in those systems that under-report charges attributed to partial (or incomplete) episodes of care. Some methodologies do not separate partial from complete episodes of care when measuring physician efficiency. Partial episodes result because a patient enrolled in a health plan during the study period or disenrolled during the study period. However, including partial episodes leads to inaccurate efficiency measurement because of under-reported episode charges—especially when some physicians have more partial episodes than other physicians.

[0039] A reason partial episodes often slip through the cracks and into an efficiency analysis is because the methodologies do not use a membership eligibility file to ensure the member is present for the entire study period. Instead, the methods assume that a condition-specific episode of care is complete if the episode exceeds some minimum duration time period. For example, if a patient's episode of diabetes is 40 days or more in duration, then the episode is marked as complete—and not partial. If a patient's diabetes episode is 39 days or less, then the episode is marked as partial.

[0040] Applying an indiscriminate time period duration to condition-specific episodes produces a high percentage of episodes marked as complete, which are actually partial (or incomplete) episodes. That is, many health plan's have membership turnover rates of 20% or higher. Consequently, a diabetes episode of 40 days duration—marked as complete—has at least a 20% chance of being a partial episode of care because of membership turnover. The end result may be physician efficiency differences that are attributed to the inclusion of partial episodes—and not to treatment patterns variation.

[0041] The ninth error happens in physician efficiency measurement systems that over-report charges attributed to episode endpoints. Some methodologies do not appropriately end a patient's episode of care before measuring a physician's efficiency. For example, chronic conditions may continue indefinitely and, therefore, patient episodes of care may be of various durations (e.g., 60 days or 600 days)—depending on the amount of available patient claims data. The end result may be physician efficiency differences that are attributed to excessively long or variable chronic condition episode durations—and not to treatment patterns variation.

[0042] The tenth error takes place in those systems that impose few requirements for having a minimum number of episodes in a certain number of medical conditions. Many methodologies do not require a minimum number of condition-specific episodes when comparing a physician's efficiency to a peer group. Instead, only a small handful (e.g., less than 10 episodes) are enough. However, there may be significant episode of care heterogeneity in one or two condition-specific episodes—even after applying a sophisticated severity-of-illness index. Consequently, examining an episode here-and-there for a physician may introduce significant error into a physician's efficiency measurement. The end result may be physician efficiency differences that are attributed to the heterogeneity in the low number of episodes examined—and not to treatment patterns variation.

[0043] Various systems have been patented in the episode of care field. Such systems are shown, for example, in U.S. Pat. Nos. 5,557,514, 5,835,897 and 5,970,463. However, none of these systems adequately overcome the aforementioned problems with respect to appropriately building and analyzing episodes of care. As importantly, existing systems fail to discuss an episode-of-care-based system for measuring individual or physician group efficiency measurement.

[0044] In one aspect, the present invention provides a method of determining physician efficiency. The method comprises: obtaining medical claims data; performing patient analysis using the obtained medical claims data to form episodes of care; performing output process based on performed patient analysis, the output process comprising at least one act selected from the group consisting of: eliminating partial episodes of care and episodes of care marked with comorbidities; assigning episodes to physicians; grouping claim line items in episodes to service categories; and applying a maximum duration rule to episodes of care; assigning at least one physician to a report group; determining eligible physicians and episode assignments by performing at least one act selected from the group consisting of: eliminating physicians from the report group, the eliminated physicians having specialties that are not assigned to a grouping of medical conditions that account for some episodes treated by a physician having a specialty type; eliminating physicians that are not in a report group of interest; and eliminating episode assignments not meeting a selected criterion; calculating condition-specific episode statistics; calculating weighted episode statistics across medical conditions; and determining efficiency scores for physicians from the calculated condition-specific episode statistics and the weighted episode statistics calculated across medical conditions.

[0045] In an embodiment, the act of calculating condition-specific episode statistics comprises calculating condition-specific episode statistics for physicians in the report group. In an embodiment, the act of calculating condition-specific episode statistics comprises calculating condition-specific episode statistics for peer groups. In an embodiment, the act of calculating weighted episode statistics comprises calculating peer group weighted episode statistics across medical conditions. In an embodiment, the act of calculating weighted episode statistics comprises calculating physician weighted episode statistics across medical conditions.

[0046] In another aspect, the present invention provides a computer program product tangibly embodied in computer instructions which, when executed by a computer, determine physician efficiency. The computer instructions, when executed, perform the acts of: obtaining medical claims data; performing patient analysis using the obtained medical claims data to form episodes of care; performing output process based on performed patient analysis, the output process comprising at least one act selected from the group consisting of: eliminating partial episodes of care and episodes of care marked with comorbidities; assigning episodes to physicians; grouping claim line items in episodes to service categories; and applying a maximum duration rule to episodes of care; assigning at least one physician to a report group; determining eligible physicians and episode assignments by performing at least one act selected from the group consisting of: eliminating physicians from the report group, the eliminated physicians having specialties that are not assigned to a grouping of medical conditions that account for some episodes treated by a physician having a specialty type; eliminating physicians that are not in a report group of interest; and eliminating episode assignments not meeting a selected criterion; calculating condition-specific episode statistics; calculating weighted episode statistics across medical conditions; and determining efficiency scores for physicians from the calculated condition-specific episode statistics and the weighted episode statistics calculated across medical conditions.

[0047] In an embodiment, the act of calculating condition-specific episode statistics comprises calculating condition-specific episode statistics for physicians in the report group. In an embodiment, the act of calculating condition-specific episode statistics comprises calculating condition-specific episode statistics for peer groups. In an embodiment, the act of calculating weighted episode statistics comprises calculating peer group weighted episode statistics across medical conditions. In an embodiment, the act of calculating weighted episode statistics comprises calculating physician weighted episode statistics across medical conditions.

[0048] In yet another aspect, the present invention provides a system for determining physician efficiency. The system comprises means for obtaining medical claims data; means for performing patient analysis using the obtained medical claims data to form episodes of care; means for performing output process based on performed patient analysis, the output process comprising at least one act selected from the group consisting of: eliminating partial episodes of care and episodes of care marked with comorbidities; assigning episodes to physicians; grouping claim line items in episodes to service categories; and applying a maximum duration rule to episodes of care; means for assigning at least one physician to a report group; means for determining eligible physicians and episode assignments by performing at least one act selected from the group consisting of: eliminating physicians from the report group, the eliminated physicians having specialties that are not assigned to a grouping of medical conditions that account for some episodes treated by a physician having a specialty type; eliminating physicians that are not in a report group of interest; and eliminating episode assignments not meeting a selected criterion; means for calculating condition-specific episode statistics; means for calculating weighted episode statistics across medical conditions; and means for determining efficiency scores for physicians from the calculated condition-specific episode statistics and the weighted episode statistics calculated across medical conditions.

[0049] In an embodiment, the means for calculating condition-specific episode statistics comprises means for calculating condition-specific episode statistics for physicians in the report group. In an embodiment, the means for calculating condition-specific episode statistics comprises means for calculating condition-specific episode statistics for peer groups. In an embodiment, the means for calculating weighted episode statistics comprises means for calculating peer group weighted episode statistics across medical conditions. In an embodiment, the means for calculating weighted episode statistics comprises means for calculating physician weighted episode statistics across medical conditions.

[0050] In yet another aspect, the present invention provides a method of performing patient health risk stratification, the method comprising: obtaining medical claims data; performing patient analysis using the obtained medical claims data to form episodes of care; and performing output process based on performed patient analysis, the output process comprising at least one act selected from the group consisting of: eliminating partial episodes of care and episodes of care marked with comorbidities; assigning episodes to physicians; grouping claim line items in episodes to service categories; and applying a maximum duration rule to episodes of care.

[0051] In yet another aspect, the present invention provides a computer program product tangibly embodied in computer instructions which, when executed by a computer, performs patient health risk stratification. The computer instructions, when executed, perform the acts of: obtaining medical claims data; performing patient analysis using the obtained medical claims data to form episodes of care; and performing output process based on performed patient analysis, the output process comprising at least one act selected from the group consisting of: eliminating partial episodes of care and episodes of care marked with comorbidities; assigning episodes to physicians; grouping claim line items in episodes to service categories; and applying a maximum duration rule to episodes of care.

[0052] In yet another aspect, the present invention provides a system for performing patient health risk stratification. The system comprises: means for obtaining medical claims data; means for performing patient analysis using the obtained medical claims data to form episodes of care; and means for performing output process based on performed patient analysis, the output process comprising at least one act selected from the group consisting of: eliminating partial episodes of care and episodes of care marked with comorbidities; assigning episodes to physicians; grouping claim line items in episodes to service categories; and applying a maximum duration rule to episodes of care.

[0053] Additional features and advantages of the present invention will be realized by one skilled in the art upon reading the following detailed description, when considered in conjunction with the accompanying drawings.

[0060] Medical claims data is utilized in an embodiment of the present invention, and generally consists of a family, member, claim, and claim line item (CLI) structure. A claim generally consists of one or more CLIs. The claims data consists of medical events that are incurred by the patient visiting a healthcare professional or a facility in the ambulatory, outpatient, inpatient, home, and other environments where medical services may be delivered.

[0061] In order to form longitudinal episodes of care, assign them to physicians, and analyze individual physician efficiency, medical claims data must be mapped to the system requirements of the present invention. The process maps medical claims by performing field mapping and field value mapping. In field mapping, fields in the source data are identified that correspond to each of the required fields. In field value mapping, for each field where applicable, the user determines the field value that corresponds to each possible value that may occur in the source data.

[0062] Five types of data are mapped: client-defined codes, value fields, dates, system-specific codes, and standard codes. The present invention uses client-defined codes for physicians and members. Value fields include dollar amount, counts, and similar numeric data according to specified value formats. Calendar dates are mapped according to the specified standard format. System-specific codes include provider type, place of service, physician specialty, type of service, and similar codes. Standard codes include CPT codes, ICD.9 procedural codes, and similar codes.

[0063] A record refers to a CLI. The mapped claims file consists of one output record for each record in the source data, except those that are duplicates resulting from adjudication process. The field byte size is noted in Table 1 below. Each record is terminated by a one byte end-of-line character.

[0064] The present invention uses the fields in the following table. Mandatory fields must be filled for all records in the order listed for correct functionality of the present invention. Non-mandatory fields are optional.

[0065]

TABLE 1
CLI Mapping Code Fields
Field				Mandatory or
Number	Type	Name & Description	Format	Non-mandatory
1	1	Primary subscriber identifier. The subscriber number used to	15 char	M
		identify a family unit.
2	1	Member identifier. The unique identifier of a person within	15 char	M
		a family. The field value should uniquely identify an
		individual when combined with the primary subscriber
		identifier (field #1).
3	3	Claim start date. Date of first service on a claim.	8 date	NM
			yyyymmdd
4	3	Claim end date. Date of last service on a claim.	8 date	NM
			yyyymmdd
5	—	Not applicable to commercial market.	15 char	—
6	5	Subscriber's mailing address. The zip code of the	15 char	NM
		subscriber's address.
7	4	Gender code. The gender for this CLI.	1 char, enum	NM
8	4	Race code. The race identifier for this CLI.	1 char, map	NM
9	3	Member's date of birth. The date of birth for the member on	8 date	M
		this CLI. The entry in this field is used to calculate the	yyyymmdd
		member's age.
10	4	Member status code. The entry in this field is used to	2 char	M
		identify members who will be analyzed. Once a study	Field must = 10
		population is identified, each member should be assigned a	for member
		value of 10 in this field. Otherwise, the ember will not be	to be
		processed.	processed
11	1	Referring provider identifier. Defines the provider that	15 char	NM
		referred a member to another provider that generated the
		specific claim of interest.
12	5	Procedure code year. The year that a specific CPT-4,	1 char	NM
		HCPCS, UB-92, or ICD.9 procedure code was used on a
		claim.
13	—	Not applicable to commercial market.	3 char	—
14	—	Not applicable to commercial market.	20 char	—
15	1	Performing provider identifier. This field refers to the	15 char	M
		provider that billed for the specific CLI.
16	4	Provider type code. The type of billing entity that delivered	1 char, map	M
		the service for this CLI.
17	4	Physician specialty code. The specialty under which the	2 char, map	M
		physician or other health care professional delivered the
		service for this CLI when delivered for payment.
18	—	Not applicable to commercial market.	1 char	—
19	—	Not applicable to commercial market.	1 char	—
20	2	Line item service count. The number of services performed	4 char	M
		on a specific CLI.
21	—	Not applicable to commercial market.	1 char	—
22	4	Place of service code. The place where the unique service	2 char, map	M
		of this line item was rendered to the patient.
23	3	Claim line item (CLI) start date. This field refers to the date	8 date	M
		of the first service on a CLI	yyyymmdd
24	3	CLI end date. Date of last service on a CLI.	8 date	M
			yyyymmdd
25	5	Procedure code. The specific CPT-4, HCPCS, ICD.9	5 char	M
		procedure, UB-92, and other procedure codes used to
		identify a specific service.
26	5	Initial procedure code modifier. Used to add an initial	2 char	NM
		modifier to a procedure code.
27	5	Second procedure code modifier. This field is used to add a	2 char	NM
		second modifier to a procedure code.
28	4	BETOS Code. Every CLI processed by the system expect	3 char	M
		those submitted on UB-92 forms must have a BETOS code.
29	5	National drug code. The national drug code (NDC) that	11 char	NM
		identifies a specific prescription drug by product name,
		formulation, and quantity.
30	—	Not applicable to commercial market.	7 char	—
31	2	Allowed charge amount. The allowed charge amount, often	10 char	M
		referred to the covered charge amount. Allowed charges
		typically equal submitted charges minus ineligible charges
		and discounts. They include (are the sum of) paid,
		copay/deductible/coinsurance, and COB.
32	—	Not applicable to commercial market.	2 char	—
33	—	Not applicable to commercial market.	1 char	—
34	5	CLI diagnosis code. The primary ICD.9 diagnosis code on a	5 char	M
		CLI.
35	4	Detailed grouping code. A detailed grouping code is a	15 char	NM
		client-specified identifier that is the base data element
		aggregated together to form a report group. For example,
		zip codes or tax identification numbers could be detailed
		grouping codes.
36	5	Secondary CLI diagnosis code. The secondary ICD.9	5 char	NM
		diagnosis code on a CLI.
37	5	Tertiary CLI diagnosis code. The tertiary ICD.9 diagnosis	5 char	NM
		code on a CLI.

[0066] Provider type codes (Field 16) identify the type of billing entity that delivered a service to a patient. The defined provider types are: none, physician, facility, pharmacy, independent service provider, and other. For none, no provider type is identified. Physicians are professionals delivering medical care services, not just physicians. This provider type includes physicians, chiropractors, acupuncturists, podiatrists, nurse practitioners, physical therapists, and other professionals delivering medical care services. Facility includes hospital inpatient, hospital outpatient, long term nursing homes, intermediate nursing homes, skilled nursing homes, rehabilitation facilities, end-stage renal disease facilities, and similar facilities. Pharmacy includes walk-in or mail-order pharmacies. This provider type is used by the present invention to identify the use of a prescription drug. Independent service providers include providers that are not associated with a facility or a physician's office, such as independent laboratories and imaging centers. Typically, an independent service provider delivers services that, depending on physician office capabilities, could be provided in a physician's office directly. Other is healthcare services such as durable medical equipment providers, medical supply providers, ambulance, home meal delivery, and other similar providers. Table 2 shows the provider type codes.

[0067]

TABLE 2
Provider Type Codes
	Provider Type	Code
	None	0
	Physician	1
	(This value is not applicable to commercial populations.)	2
	Facility	3
	Pharmacy	4
	Independent service provider	5
	Other	6

Table 3 shows physician specialty codes (Field 17).

[0068]

TABLE 3
Physician Specialty Codes
Specialty	Code
None (Use this code when physician is not the provider type)	0
Allergist	1
Allied Practitioner	2
Anesthesiology	3
Anesthesiology Assistant	4
Cardiology	5
Cardiothoracic surgery	6
Chiropractor	7
Dermatology	8
Emergency Medicine	9
Endocrinology	10
Family/General Practice	11
Gastroenterology	12
General Internist	13
General surgery	14
Genetic	15
Infectious Disease	16
Neonatal Care	17
Nephrology	18
Neurology	19
Neurosurgery	20
Obstetrician/Gynecologist	21
Oncology/Hematology	22
Ophthalmology	23
Optometry	24
Oral-maxillofacial Surgeon	25
Orthopedist	26
Otolaryngology (ENT)	27
Pain management	28
Pathology	29
Pediatrics	30
Plastic surgery	31
Podiatry	32
Psychiatry	33
Psychologist	34
Psychology Professional (e.g., social worker)	35
Pulmonology	36
Radiology	37
Rheumatology	38
Sports and physical medicine	39
Urology	40
Vascular surgeon	41
Critical care	42
Other	99

The place of service code identifies where a unique service was provided to a patient (e.g., office, outpatient facility of a hospital, inpatient facility of a hospital). Table 4 shows the place of service codes (Field 22)

[0069]

TABLE 4
Place of Service Codes
Place of Service	Code	Description
None	0	No place of service code or unknown place of service.
Office	1	Service delivered in a physician's office.
Home	2	Service delivered in a patient's home environment.
Emergency room	3	Service delivered in the emergency room department of a hospital.
Urgent care facility	4	Service delivered in an urgent care facility.
Inpatient hospital	5	Inpatient service delivered in a hospital.
Outpatient hospital	6	Outpatient service delivered in a hospital.
Ambulance	7	Service delivered in a land, air or water ambulance.
Ambulatory surgical center	8	Service delivered in a walk-in surgical center.
Birthing center	9	Service delivered in a birthing center.
Military treatment facility	10	Service delivered in a military treatment facility.
Inpatient psychiatric facility	11	Service delivered on an inpatient basis at a psychiatric facility for
		mental health or chemical dependency.
Public health clinic	12	Service delivered in a state or local public health clinic or a rural
		health clinic.
Independent laboratory	13	Service delivered at an independent laboratory.
Alternative care facility	14	Service delivered in an alternate care facility such as a skilled
		nursing facility, nursing facility, custodial care facility, hospice,
		adult living care facility (ACLF), psychiatric facility partial
		hospitalization, community mental health center, intermediate care
		facility/mentally retarded, residential substance abuse treatment
		facility, psychiatric residential treatment center, comprehensive
		inpatient rehabilitation facility comprehensive outpatient
		rehabilitation facility, end stage renal disease treatment facility, or
		similar facilities.
Other ambulatory facility	15	Service delivered in a walk-in environment such as a school,
		homeless shelter, health center, immunizations center, or similar
		facility.
Mobile unit	16	Service delivered in a unit that brings specific services to
		communities.
Other	17	Other places of service not included in the types listed in this
		table.
Pharmacy	18	Indicates that the prescription drug was dispensed by a walk-in or
		mail-order pharmacy. This includes hospital-run pharmacies that
		may dispense prescription drugs on an outpatient basis.

Type of Service (BETOS) Codes (Field 28)

[0070] In an embodiment, the present invention uses BETOS (Berenson-Eggers type of service) Codes as the type of service code (Field 28). The BETOS Code system is a procedure code system that organizes procedures and services into groupings that have been generally accepted as clinically meaningful. The BETOS Code system categories allow objective assignment of procedures and services. A BETOS Code must be assigned for each service on a CLI (e.g., CPT-4, HCPCS), except those submitted on UB-92 forms. Any homegrown codes or other special service codes that do not have BETOS Code must be mapped to a specific BETOS Codes.

[0071] In an embodiment, the present invention groups all health services with a BETOS Code into one of 11 service categories. Moreover, an embodiment of the present invention also groups all health services with a BETOS Code into one of 21 sub-service categories. Services without a BETOS Code will be assigned to our other medical services category. In an embodiment, alternative CLI health services grouping system may be applied other than BETOS codes.

[0072] The services provided during an episode of care are separated into the following 11 service categories and 21 sub-service categories presented below.

[0073] Category 0 is the overall results in the output files. The overall results are normally presented in the 0 row or the 0 section of the output file. This category captures the overall information for a physician. In an embodiment, the present invention calculates overall charges, but does not calculate overall utilization. As a result, the overall utilization entry 0 row is used to present the average duration (in days).

[0074] The professional visits (prof visits) service category presents charges and utilization for professional visits incurred in the physician's office, clinic or outpatient department of a hospital. For utilization, the numerator unit is visits. The sub-service category also is professional visits. This sub-service category presents charges and utilization for professional visits incurred in the physician's office, clinic, or outpatient department of a hospital.

[0075] The diagnostic tests (diag tests) service category presents charges and utilization for diagnostic tests incurred in the physician's office, clinic, outpatient department of a hospital, or surgicenter. Diagnostic tests represent imaging tests (X-rays, CAT scans, MRIs, etc.), functional tests (EKGs, echocardiograms, etc.), and invasive tests. There are three sub-service categories for diagnostic testing. The first sub-service category is imaging tests. This sub-service category presents charges and utilization for imaging tests, which include x-rays, CAT scans, MRI, and other related imaging tests. For utilization the numerator unit is services or tests. The second sub-service category is invasive testing. This sub-service category presents charges and utilization for angiography, cardiac catheterization, myocardial imaging, myelography, and other related invasive testing. For utilization, the numerator unit is services or tests. The third sub-service category is functional testing. This sub-service category presents charges and utilization for electrocardiograms, cardiovascular stress tests, echography, and other related functional testing. For utilization, the numerator unit is services or tests.

[0076] The laboratory and pathology (lab/path) service category presents charges and utilization for laboratory and pathology services incurred in the physician's office, clinic, outpatient department of a hospital, or surgicenter. For utilization, the numerator unit is services. There are two sub-service categories. The first sub-service category is laboratory (lab). This sub-service category presents charges and utilization for laboratory services incurred in the physician's office, clinic, outpatient department of a hospital, or surgicenter. For utilization, the numerator unit is services. The second sub-service category is pathology (path). This sub-service category presents charges and utilization for pathology services incurred in the physician's office, clinic, outpatient department of a hospital, or surgicenter. For utilization, the numerator unit is services.

[0077] The medical and surgical procedures (med/surg) service category presents charges and utilization for medical and surgical procedures incurred in the physician office, clinic, outpatient department of a hospital, and surgicenter. For utilization, the numerator unit is services or procedures. There are two sub-service categories. The first sub-service category is medical (med). This sub-service category presents charges and utilization for opthalmological services (including eye exams), electro-oculography, otolaryngologic exam, evaluation of speech/voice, cardiac rehabilitation, muscle testing, neurobehavioral exams, and related medical procedures. For utilization, the numerator unit is services or procedures. The second sub-service category is surgical (surg). This sub-service category presents charges and utilization for surgical procedures incurred in the physician office, clinic, outpatient department of a hospital, or surgicenter. For utilization, the numerator unit is services or procedures.

[0078] The prescription drugs (Rx) service category presents charges and utilization for outpatient and ambulatory prescription drugs. For utilization, the numerator unit is prescription drug fills. The sub-service category also is prescription drugs. This sub-service category presents charges and utilization for outpatient and ambulatory prescription drugs.

[0079] The professional inpatient services (prof inpt) service category presents charges and utilization for all inpatient professional services. For utilization, the numerator unit is services. The sub-service category also is inpatient professional.

[0080] The facility outpatient visits (outpt facility) service category presents charges and utilization for services incurred in an outpatient department of a hospital or surgicenter. For utilization, the numerator unit is visits. There are two sub-service categories. The first sub-service category is emergency room facility. This sub-service category presents charges and utilization for emergency room facility services. For utilization, the numerator unit is visits. The second sub-service category is other outpatient facility. This sub-service category presents charges and utilization for other outpatient facility services, including medical/surgical, rehabilitation, and other services incurred in an outpatient department of a hospital or surgicenter. For utilization, the numerator unit is visits.

[0081] The facility inpatient days (hosp inpt days) service category presents charges and utilization for inpatient days for all hospital inpatient facility services. For utilization, the numerator unit is hospital inpatient days. The sub-service category also is inpatient facility days.

[0082] The facility inpatient admissions (hosp inpt admits) service category presents utilization for admissions for all hospital inpatient facility services. For utilization, the numerator unit is admissions. Charges are not presented for this service category. For charges, this service category is entered as “0,” because the episode charge component is assigned to the Facility Inpatient Days service category. The sub-service category also is inpatient facility admissions.

[0083] The alternative sites (altern sites) service category presents charges and utilization for skilled nursing facility and half-way home services. For utilization, the numerator unit is services. The sub-service category also is alternative sites.

[0084] The other medical services (other med) service category presents charges and utilization for other professional medical services incurred in the physician's office, clinic, outpatient department of a hospital, and dialysis center. Other medical services include physical therapy, chiropractic services (other than professional visits), chemotherapy and radiation, dental, durable medical equipment, and ambulance services. For utilization, the numerator unit is services. There are six sub-service categories. The first sub-service category is physical therapy. This sub-service category presents charges and utilization for manual therapy, electric simulation and other modalities, orthotics training, prosthetic training, and related physical therapy services. For utilization, the numerator unit is services.

[0085] The second sub-service category is dialysis. This sub-service category presents charges and utilization for end-stage renal disease (ESRD), hemodialysis, hemoperfusion, and related dialysis services. For utilization, the numerator unit is services. The third sub-service category is chemo/radiology. This sub-service category presents charges and utilization for chemotherapy administration, provision of chemotherapy agents, radiation dosimetry, brachytherapy isodose plans, radiation treatment delivery, and other related chemo/radiation services. For utilization, the numerator unit is services. The fourth sub-service category is anesthesia. This sub-service category presents charges and utilization for anesthesia. For utilization, the numerator unit is services. The fifth sub-service category is durable medical equipment (DME). This sub-service category presents charges and utilization for crutches, walkers, commode chairs, pressure pads, beds, portable oxygen, breast pumps, infusion supplies, wheelchairs, and related DME services. For utilization, the numerator unit is services. The sixth sub-service category is other medical care. This sub-service category presents charges and utilization for other medical care not easily classified elsewhere (e.g., ambulance, influenza immunization, dental not classified elsewhere). For utilization, the numerator unit is services.

Step 1. Build Flattened CLI Structure Input File

[0086] The traditional structure of CLI input files is hierarchical. In a hierarchical structure, there is a family (or subscriber) unit, and the individual members within the family are associated with the family unit. Then, the claim submissions for a member are associated to the member. This claim record generally contains information such as provider ID, provider specialty type, name of provider, and place of service. Finally, the CLIs within a claim are associated with the particular claim. The CLIs generally contain the detailed record information of each individual service rendered by the healthcare provider (e.g., CPT-4 code, ICD.9 (diagnosis) codes, number of services provided, service start and end dates).

[0087] Therefore, in a hierarchical structure, there are at least four different record types: family, member, claim, and CLI.

[0088] An advantage of the hierarchical structure is that it gives the user one data file, which generally is easy to manage. Furthermore, this structure is intuitive, as the structure is generally how claims processors at health plans think about organizing the submitted claims data.

[0089] The disadvantage of the hierarchical structure is that reading the records from the claim input file into the software takes significantly more CPU requirements as compared to the flattened CLI structure employed in embodiments of the present invention. Therefore, the hierarchical structure requires significantly higher software system processing time.

[0090] For the flattened CLI structure, there is only one record type produced for each CLI. Moreover, all records in the file are the exact same type and format. Therefore, each record forms a block that consists of a given number of the exact same bytes.

[0091] The flattened CLI structure contains all record field information that is present in the hierarchical CLI structure. Therefore, CLI records from members in the same family need to contain repeating family, member, and some unique claim information. On the surface, one may think that the repetition of family, member, and claim field variables on each CLI record will form a larger data file as compared to the hierarchical CLI structure.

[0092] However, this is not the case because the hierarchical CLI structure requires a ‘marker’ after each record to signify the start of another record. For example, in an embodiment, a marker is needed to signify that the family record information has ended and the member information begins; a marker is needed to signify that the member information has ended and the claim information begins; and a marker is needed to signify that the claim information has ended and the first CLI information for the claim begins.

[0093] Another issue with the hierarchical CLI structure is that the number of subordinate blocks of data is variable and, therefore, separate markers must be used to encode this information. For example, a family may have from one to N number of family members. Likewise, a single member may have from one to N number of claims, and a claim may have from one to N number of CLIs. In each of these cases, some type of encoding marker must be used to include this information into the data file. Additional CPU time is used in the software to read and handle these additional markers.

[0094] The volume of required markers within the hierarchical CLI structure makes the data file size similar to that of the flattened CLI structure.

[0095] The advantage of the flattened CLI structure is that the data file is easily read into a medical claims-based software, requiring significantly less CPU requirements as compared to a hierarchical CLI structure. The reason for less CPU intensive record reading is that computers like to read fixed length records of the same type and format (i.e., blocks of data). The overall read step processing time, then, is significantly reduced.

Step 2: Read in Run.INI File

[0096] The operation of the system of the present invention is influenced by parameters. Parameters are named controls found within the system of the present invention run initialization file (or RUN.INI File). Controls influence the results generated by the system of the present invention. Table 6 presents the parameters in the RUN.INI file.

[0097]

TABLE 6
Parameters in the RUN.INI File
Parameter Name	Notes	Values
Module Control Programs
RUN_PATAN	Controls whether the PATAN module is executed	0 = No
	during the current run.	1 = Yes
		Initial System setting = 1
RUN_PROVSPEC	Controls where the PROVSPEC module is	0 = No
	executed during the current run.	1 = Yes
		Initial System setting = 1
RUN_PROVAN	Controls whether the PROVAN module is	0 = No
	executed during the current run.	1 = Yes
		Initial System setting = 1
General Directory Parameters
DIR_BIN	Defines the location of program files.	Directory path
DIR_SYSTABLE	Defines the location of system methodology	Directory path
	tables (see the ‘Control Tables” section of this
	manual).
DIR_DATA	Defines the root directory for all data files, both	Directory path
	input and output.
DIR_RUNTABLE	Defines the location of both data-specific tables	Directory path
	and pre-specified tables (see the “Control Tables”
	section of this manual).
FILE_PROVIDER	Defines the location of the physician specialty	File Name
	file (see the “Data-Specific Tables” section of
	this manual).
FILE_GROUPCODEMAP	Defines the detail grouping code to the aggregate	File Name
	grouping code.
Module Runtime Parameters
Grouper function
SWITCH_AGGREGATESTART	Defines the start number for the Aggregate	0 = Do not eliminate any
	Grouping Codes to be processed. For more	Aggregate Grouping Codes
	information on Aggregate Grouping Codes see	from the beginning of the list
	the chapter, “Report Group Structures”. NOTE:	N (any whole number) = Specifies
	Leave the value of this switch at 0 unless you	the first Aggregate
	want to limit the groups to be processed.	Grouping Code to be
		processed. All codes that are
		smaller than this value will
		not be processed
		Initial System setting = 0
SWITCH_AGGREGATEEND	Defines the end number of the Aggregate	0 = Do not eliminate any
	Grouping Codes to be processed. For more	Aggregate Grouping Codes
	information on Aggregate Grouping Codes see	from the end of the list
	the chapter, “Report Group Structures.”	N (any whole number) = Specifies
		the last Aggregate
		Grouping Code to be
		processed. All codes that are
		larger than this value will not
		be processed.
		Initial System setting = 0
FILE_SPECAGE	Identifies the file containing the age control table	File Name with respect to
	for each specialty.	DIR_RUNTABLE
		Initial System setting = specage.tab
FILE_MBCONDITIONS	Identifies the file that relates medical conditions	File Names with respect to
	to classifications in accordance with the present	DIR_RUNTABLE
	inventions.	Initial System setting = mbconditions.tab
PATAN
SWITCH_DROPPARTIAL	Controls whether partial episodes are included in	0 = Include
	analysis.	1 = Exclude
		Initial System setting = 1
SWITCH_DROPCOMORB	Controls whether comorbid episodes are included	0 = Include
	in analysis.	1 = Exclude
		Initial System setting = 1
SWITCH_ASSIGNTHRESHOLD	Defines a percent whereby when a physician has	Any whole number
	this percent or more of total professional charges	representing a percent
	associated with an episode, that episode is	Initial System setting = 20
	assigned to the physician. The professional
	charges considered for this threshold may occur
	in an office visit, clinic, hospital outpatient,
	hospital inpatient, or other professional setting
	(e.g., nursing home, halfway home, home visit
	professional charges). All facility charges and
	prescription drug charges are excluded.
PROVSPEC
NONE
PROVAN
SWITCH_LOWOUTPERCENT	Defines what percentage of a physician's least	0 = 0.0%
	expensive episodes will be removed from	1 = 1.0%
	analysis. PROVAN removes episodes from each	2 = 2.5%
	medical condition in the physician's	3 = 5.0%
	marketbasket separately. PROVAN starts with	4 = 10.0%
	the least expensive episode and continues	Initial System setting = 2
	removing episodes in order of expense until the
	specified percentage of episodes is reached.
SWITCH_LOWOUTDOLLAR	Sets a threshold for episode charges. All	A whole number
	episodes below the value of this switch will be	representing a dollar value.
	dropped from analysis.	Initial System setting = 20
SWITCH_HIGHOUTPERCENT	Defines what percentage of a physician's most	0 = 0.0%
	expensive episodes will be removed from	1 = 1.0%
	analysis. PROVAN removes episodes from each	2 = 2.5%
	medical condition in the physician's	3 = 5.0%
	marketbasket. PROVAN starts with the most	4 = 10.0%
	expensive episode and continues removing	Initial System setting = 3
	episodes in order of expense until the specified
	percentage of episodes is reached.
SWITCH_HIGHOUTDIFF	The parameter SWITCH_HIGHOUTDIFF	A whole number that
	determines whether a signal episode should be	represents a percent.
	removed as a high-outlier. This high-end outlier	NOTE: Should always be
	parameter is applied when one high-end outlier	≧100. If ≦100 then an
	cannot be removed under the	episode will ALWAYS be
	SWITCH_HIGHOUTPERCENT parameter. The	removed.
	value of this parameter is a whole number	Initial System setting = 250
	representing a percent. If the charges for the most
	expensive episode are at least the defined percent
	greater than the charges for the next most
	expensive episode, the most expensive episode is
	removed as a high outlier. A maximum of one
	episode for each medical condition in each
	physician's marketbasket may be removed using
	this rule.
SWITCH_MINEPCOUNT	Sets the requirement for the number of episodes a	Any whole number
	physician must treat to be included in the	Initial System setting = 2
	analysis. This parameter implements part of the
	N × 3 rule, which specifies that a physician must
	treat N episodes in three medical conditions to be
	included. For example, if the N value is equal to
	four, the rule would require four episodes in each
	of three conditions, and the rule would become,
	in effect a “4 × 3” rule.
	In the N × 3 rule:
	N = The number of episodes of a specific
	medical condition a physician must treat
	during the study period. This number
	can be changed by the user.
	3 = the minimum number of medical conditions
	in which the physician must treat episodes. The
	medical conditions must be in the physician's
	marketbasket. This number cannot be changed.
SWITCH_CONFLEVEL	Sets the p value for statistical confidence.	1 = 0.75
		(p < 0.25)
		2 = 0.90
		(p < 0.10)
		Initial System setting = 1
PATAN Date Parameters
STUDYSTARTDATE	Defines the start date of the study period.	A date in the format
		yyyymmdd
STUDYENDDATE	Defines the end date of the study period.	A date in the format
		yyyymmdd
STUDYMIDDATE	Sets the midpoint date of the study period. A	A date in the format
	chronic episode of care must start on or before	yyyymmdd
	this date.
STUDYQ4DATE	Defines the date that is the end of the third	A date in the format
	quarter of the study period (the last day before the	yyyymmdd
	fourth quarter starts). An acute episode of care
	from a medical condition with a window period
	≧120 days must start on or before this date.
Slider Parameters
STUDYSLIDER1_START	Sets the start date of the slider period for Slider 1.	A date in the format
		yyyymmdd
STUDYSLIDER1_END	Sets the end date of the slider period for Slider 1.	A date in the format
		yyyymmdd
STUDYSLIDER2_START	Sets the start date of the slider period for Slider 2.	A date in the format
		yyyymmdd
STUDYSLIDER2_END	Sets the end date of the slider period for Slider 2.	A date in the format
		yyyymmdd
Module Runtime Output Directory Parameters - Within DIR_DATA
DIR_PATSORT	Identifies the subdirectory that receives the	Directory name
	PATSORT output. This subdirectory is within the	Initial System setting = patsort
	DIR_DATA directory path.
DIR_PATAN	Identifies the subdirectory that receives the	Directory name
	PATAN output. This subdirectory is within the	Initial System setting = patan
	DIR_DATA directory path.
DIR_PROVSORT1	Identifies the subdirectory that receives the	Directory name
	PROVSORT1 output. This subdirectory is within	Initial System setting = provsort1
	the DIR_DATA directory path.
DIR_PROVSPEC	Identifies the subdirectory that receives the	Directory names
	PROVSPEC output. This subdirectory is within	Initial System setting = provspec
	the DIR_DATA directory path.
DIR_PROVSORT2	Identifies the subdirectory that receives the	Directory name
	PROVSORT2 output. This subdirectory is within	Initial System setting = provsort2
	the DIR_DATA directory path.
DIR_PROVAN	Identifies the subdirectory that receives the	Directory name
	PROVAN output. This subdirectory is within the	Initial System setting = provan
	DIR_DATA directory path.
Data file Parameters - within DIR_DATA
COREFILE	Defines the subdirectory and filename that	Directory name/File name
	contains the input claims file. The subdirectory is	Initial System setting = extract/
	within the DIR_DATA directory path.	corefields
CORESORTED	Defines the subdirectory and filename that	Directory name/File name
	contains the sorted claims file. The subdirectory	Initial System setting = patsort/
	is within the DIR_DATA directory path.	sampledata. sort
ASNFILE	Defines the subdirectory and filename that	Directory name/File name
	contains the output file from PATAN. The	Initial System setting = patan/
	subdirectory is within the DIR_DATA directory	assign.tab
	path.
ASNSORTED	Defines the subdirectory and filename that	Directory name/File name
	contains the sorted output file from PATAN. The	Initial System setting = provsort1/
	subdirectory is within the DIR_DATA directory	assign. tab.sort
	path.
ASNSPECFILE	Defines the subdirectory and filename that	Directory name/File name
	contains the output file from PROVSPEC. The	Initial System setting = provspec/
	subdirectory is within the DIR_DATA directory	assignspec.tab
	path.
ASNSPECSORTED	Defines the subdirectory and filename that	Directory name/File name
	contains the sorted output file from PROVSPEC.	Initial System setting = provsort2/
	The subdirectory is within the DIR_DATA	assignspec.tab.sort
	directory path.
SCOREFILE	Defines the subdirectory and filename that	Directory name/File name
	contains one of the two final output files. The	Initial System setting = provan/
	subdirectory is within the DIR DATA directory	score.tab
	path.
DETAILFILE	Defines the subdirectory and filename that	Directory name/File name
	contains one of the two final output files. The	Initial System setting = provan/
	subdirectory is within the DIR_DATA directory	detail.tab
	path.

Step 3: Read in CLIs from Flattened CLI Structure

[0098] The CLIs in the Flattened CLI Structure are now read into the patient sort (PATSORT). PATSORT sorts CLIs by the primary sort key of member (or patient) and the secondary sort key of date of service on each CLI. During PATSORT, all CLIs with zero dollars in charges ($0) are removed from further analysis.

Step 4: Apply Sliders

[0099] An embodiment of the present invention uses sliders to establish that a member was present during an ongoing condition-specific episode of care. The purpose of sliders is to establish the presence of members during ongoing condition-specific episodes of care without using an eligibility file. Often, membership eligibility files are not readily accessible to the user.

[0100] An embodiment of the present invention employs two sliders, each of which can be set with a start date and an end date. These dates can be set by the user. The period that includes the start and end dates and the time in between is the slider period. The use of sliders allows the user to establish that a member was present at least for some period of time near the beginning and near the end of the study period. If so, then the user concludes that the member was present during the ongoing condition-specific episode of care.

[0101] An embodiment of the present invention checks to see that the member was represented by a CLI that began and ended during each slider period. If not, then the member and all CLIs related to that member are removed from the analysis.

[0102] The two sliders are referred to herein as Slider 1 and Slider 2. Slider period settings for a calendar year study period are as follows: Slider 1 is set for the time period of January 1 through June 30. (If not using a calendar year, then use the first six months of the study period.) Slider 2 is set for the time period of July 1 through December 31. (If not using a calendar year, then use the second six months of the study period.) With these settings, a member must have a claim in both the first and second halves of the year to be included in the analysis.

[0103] Table 7 illustrates examples of suggested slider settings for a study period that starts on January 1 and ends on December 31.

[0104]

TABLE 7
Recommended Slider Settings
Example #	Slider Settings	Notes
1	Slider period 1: January 1	With these settings, a member must have one final adjudicated
	through June 30	claim in each slider period to be included in the analysis. These
	Slider period 2: July 1	settings increase the likelihood that a member included in the
	through-December 31	analysis was in fact present during an ongoing episode of care.
2	Slider period 1: March 1	A member who has one final adjudicated claim during slider
	through December 31	period 1 is assumed to be present during the entire year. Slider 2 is
	Slider period 2: March 1	ignored because its slider period is identical to Slider 1's period.
	through December 31	This setting keeps many members in the analysis.

Step 5: Perform PATAN Analysis to Form Episodes of Care

[0105] The Patient Analysis (PATAN) forms episodes of care using a Grouper function explained herein. The Grouper function is based on the International Classification of Diseases, 9^th revision (ICD.9) and the Current Procedural Terminology, 4^th edition (CPT-4). The Grouper function groups together over 14,000 unique ICD.9 diagnosis codes into 526 meaningful medical conditions. Each ICD.9 code is assigned to a single medical condition.

[0106] The resulting 526 medical conditions are formed based on clinical homogeneity with respect to generating a similar clinical response from physicians treating a patient. Table M shows selected ICD.9 codes mapped to several medical conditions.

[0107]

TABLE M
Selected Diagnosis (ICD.9) Codes Mapped to Medical Conditions
Medical
Condition	Medical Condition	ICD.9
Number	Long Description	Codes	Brief Description
5.2	Conjunctivitis	077.0	Conjunctivitis, inclusion
		077.8	Conjunctivitis, viral
		372.0	Conjunctivitis, acute
		372.01	Conjunctivitis, serous
		372.1	Conjunctivitis, chronic
		372.14	Conjunctivitis chronic allergic
		372.22	Contact blepharonconjunctivitist
6.5	Otitis media	381	Eustachian tube disorder
		381.02	Acute mucoid otitis media
		381.06	Acute allergic sanguinous otitis media
		381.20	Chronic mucoid otitis media
		382	Suppurative otitis media
		382.00	Acute suppurative otitis media
		382.4	Suppurative otitis media
		382.01	Acute suppurative, with drum rupture
		382.1	Chronic tubotympanic suppurative
7.2	Sinusitis	461.0	Acute maxillary sinusitis
		461.2	Acute ethomoidal sinusitis
		461.3	Acute sphenoidal sinusitis
		473	Chronic sinusitis
		473.2	Chronic ethmoidal sinusitis
		473.3	Chronic sphenoidal sinusitis
9.11	Asthma	493.0	Extrinsic asthma
		493.02	Extrinsic asthma, acute exacerbation
		493.1	Intrinsic asthma
		493.01	Extrinsic asthma, status asthmaticus
		493.2	Chronic obstructive asthma
		493.21	Chronic obstructive, status asthmaticus
10.2	Hypertension	401.1	Benign essential hypertension
		405.1	Secondary benign hypertension
		402	Hypertensive heart disease
		402.0	Hypertensive heart disease, malignant
		403.00	Hypertension renal, malignant
		403.1	Hypertension renal, benign disease
		405.0	Secondary malignant hypertension
		402.11	Hypertensive heart, malignant, heart failure
		404.01	Hypertensive heart/renal, malignant health failure
		404.11	Hypertensive heart/renal, benign, heart failure

The 526 medical conditions are placed into one of 37 Principle Medical Condition Groups (PMC Groups). The PMC Groups generally represent organ, body, or medical condition types (e.g., PMC Group 5-Eye Conditions; PMC Group 9-Respiratory Conditions; PMC Group 24-Mental Disorders). Table 8 presents the list of PMC Groups.

[0108]

TABLE 8
Principle Medical Condition (PMC) Groups
Principle Medical
Condition	PMC Group	PMC Group
Groups	Long Description	Abbreviated Description
1	Preventive Care	Preventive Care
2	Infectious and Parasitic Diseases	Infectious & Parasitic Dz
3	Human Immunodeficiency Infections	HIV Infections
4	Nervous System Conditions	Nervous System Conditions
5	Eye Conditions	Eye Conditions
6	Ear Conditions	Ear Conditions
7	Nose Conditions	Nose Conditions
8	Mouth Conditions	Mount Conditions
9	Respiratory Conditions	Respiratory Conditions
10	Heart and Pulmonary Conditions	Heart and Pulmonary Cond
11	Cerebrovascular and Artery Conditions	Cerebrovasc & Artery Cond
12	Vein and Lymphatic Conditions	Vein & Lymphatic Cond
13	Digestive System Conditions	Digestive System Cond
14	Hernias	Hernias
15	Hepatobiliary System and Pancreas	Hepatobiliary Sys & Pancreas
16	Thyroid Disorders	Thyroid Disorders
17	Diabetes Mellitus	Diabetes Mellitus
18	Other Endocrine Disorders	Other Endocrine Disorders
19	Metabolic Disorders	Metabolic Disorders
20	Immunity and Blood Disorders	Immunity & Blood Disorders
21	Lymphatic and Hematopoietic Tissue	Lymph & Hematopoietic Tiss
22	Urinary Tract and Kidney Conditions	Urinary Tract & Kidney Cond
23	Female Reproductive Conditions	Female Reproductive Cond
24	Male Reproductive Conditions	Male Reproductive Cond
25	Infertility Treatment	Infertility Treatment
26	Maternity-Related Conditions	Maternity-Related Cond
27	Neonatal Conditions	Neonatal Conditions
28	Congenital Anomalies	Congenital Anomalies
29	Skin and Subcutaneous Tissue Conditions	Skin & Subcutaneous Tissue
30	Breast Conditions	Breast Conditions
31	Musculoskeletal Conditions	Musculoskeletal Conditions
32	Upper Limb Conditions	Upper Limb Conditions
33	Lower Limb Conditions	Lower Limb Conditions
34	Mental Disorders	Mental Disorders
35	Burns	Burns
36	Other Medical Conditions	Other Medical Conditions
37	Replaced Diagnosis Codes	Replaced Diagnosis Codes

Within each PMC Group, medical conditions are listed in ascending order of expected resource intensity level and physiologic progression of the condition or disease (from least resource intensive and physiologic progression to the most resource intensive and physiologic progression). Table 9 shows an example for PMC Group 6, Ear Conditions.

[0109]

TABLE 9
PMC Group 6-Ear Conditions
Medical
Condition	Medical Condition
Number	Long Description
6	Ear Conditions
6.1	Otitis externa
6.2	Wax in ear
6.3	Open wound of ear
6.4	Other disorders of ear
6.5	Otitis media
6.6	Disorders of tympanic membrane
6.7	Disorders of middle ear
6.8	Vertiginous syndromes
6.9	Mastoiditis
6.10	Hearing loss
6.11	Malignant neoplasm of middle ear

The 526 medical conditions in the Grouper function account for 100% of all medical conditions and expenditures as identified by ICD.9 medical condition diagnostic codes. Each condition receives a Medical Condition Number (e.g., Medical Condition 4.1—neuritis upper and lower limbs; Medical Condition 5.16—glaucoma; Medical Condition 7.2—sinusitis; Medical Condition 9.11—asthma; Medical Condition 10.13—ischemic heart disease). Table 10 presents the list of medical conditions in the Grouper function.

[0110]

TABLE 10
List of Medical Conditions in Grouper Function
Medical			Number of
Condition	Medical Condition	Medical Condition	Severity
Number	Long Description	Abbrev Description	Classes
1	Preventive Care	Preventive Care	—
1.1	General medical exam	General medical exam	1
1.2	Gynecological exam	Gynecological exam	1
1.3	Screenings for medical conditions	Screening of med conditions	1
1.4	Vaccinations	Vaccinations	1
1.5	Prophylactic therapy	Prophylactic therapy	1
1.6	History of medical conditions	Hx of medical conditions	1
1.7	Postpartum exam	Postpartum exam	1
1.8	Surgical aftercare	Surgical aftercare	1
2	Infectious and Parasitic Diseases	Infectious & Parasitic Dz	—
2.1	Intestinal infections	Intestinal infections	1
2.2	Other bacteria disease	Other bacteria diseases	3
2.3	Drug-resistant microorganism	Drug-resistant microorganism	1
2.4	Septicemia	Septicemia	2
2.5	Tuberculosis	Tuberculosis	3
2.6	Other viral diseases	Other viral diseases	3
2.7	Chickenpox	Chickenpox	3
2.8	Herpes simplex	Herpes simplex	3
2.9	Viral warts	Viral warts	1
2.10	Infectious mononucleosis	Infectious mononucleosis	1
2.11	Cytomegalic inclusion disease	Cytomegalic inclusion dz	1
2.12	Non-arthropod-borne viral diseases	Non-arth-borne viral dz	3
2.13	Arthropod-borne diseases	Arthropod-borne dz	3
2.14	Venereal diseases	Venereal diseases	3
2.15	Other mycoses	Other mycoses	1
2.16	Cryptococcosis	Cryptococcosis	1
2.17	Candidiasis	Candidiasis	3
2.18	Coccidioidomycosis	Coccidioidomycosis	3
2.19	Histoplasmosis	Histoplasmosis	3
2.20	Blastomycotic infection	Blastomycotic infection	2
2.21	Helminthiases	Helminthiases	3
2.22	Scabies	Scabies	1
2.23	Toxoplasmosis	Toxoplasmosis	3
2.24	Pneumocystosis	Pneumocystosis	1
2.25	Other infectious diseases	Other infectious diseases	3
3	Human Immunodeficiency Infections	HIV Infections	—
3.1	HIV infection with no complications	HIV n/no complications	1
3.2	HIV infection with infectious complication	HIV with infectious comp	3
3.3	HIV infection with CNS involvement	HIV with CNS involvement	3
3.4	HIV infection with malignancy	HIV with malignancy	3
3.5	HIV infection with multiple complications	HIV with multiple comp	3
4	Nervous System Conditions	Nervous System Conditions	—
4.1	Neuritis upper and lower limbs	Neuritis upper, lower limbs	2
4.2	Peripheral neuropathy	Peripheral neuropathy	3
4.3	Headaches	Headaches	2
4.4	Disorders of cranial nerves	Disorders of cranial nerves	2
4.5	Carpal tunnel syndrome	Carpal tunnel syndrome	1
4.6	Benign neoplasm of non-CNS nerves	Benign neop non-CNS nerves	1
4.7	Nerve root and plexus disorder	Nerve root and plexus dsdr	3
4.8	Tremor disorders	Tremor disorders	2
4.9	Injury to peripheral nerves and nerve roots	Inj peripheral nerv & nerv roots	3
4.10	Neurofibromatosis	Neurofibromatosis	1
4.11	Inflammatory diseases of CNS	Inflammatory dz of CNS	1
4.12	Paralytic syndromes	Paralytic syndromes	3
4.13	Myoneural disorders	Myoneural disordes	2
4.14	Benign neoplasm of CNS	Benign neoplasm of CNS	1
4.15	Injury of spinal cord	Injury of spinal cord	3
4.16	Congenital anomalies of nervous system	Cong anomalies nerv sys	3
4.17	Parkinson's disease	Parkinson's disease	1
4.18	Seizure disorders	Seizure disorders	3
4.19	Multiple sclerosis	Multiple sclerosis	1
4.20	Other CNS diseases	Other CNS diseases	3
4.21	Muscular dystrophies	Muscular dystrophies	2
4.22	Malignant neoplasm of non-CNS nerves	Malig neop non-CNS nerves	1
4.23	Malignant neoplasm of spinal cord	Malig neop spinal cord	1
4.24	Malignant neoplasm of brain, initial care	Malig neop brain, initial	1
4.25	Malignant neoplasm of brain, active care	Malig neop brain, active	1
4.26	Malignant neoplasm of brain, inactive care	Malig neop brian, inactive	1
5	Eye Conditions	Eye Conditions	—
5.1	Refractive errors	Refractive errors	1
5.2	Conjunctivits	Conjunctivitis	2
5.3	Other disorders of conjunctiva	Other dsdr of conjunctiva	2
5.4	Infections of the eyelids	Infections of the eyelids	2
5.5	Disorders of eyelids	Disorders of eyelids	2
5.6	Disorders of lacrimal system	Dsdr of lacrimal system	2
5.7	Keratitis	Keratitis	3
5.8	Other disorders of cornea	Other disorders of cornea	3
5.9	Disorders of iris and ciliary body	Dsdr iris and ciliary body	3
5.10	Strabismus	Strabismus	3
5.11	External eye injury	External eye injury	2
5.12	Disorders of globe	Disorders of globe	3
5.13	Internal eye injury	Internal eye injury	2
5.14	Disorders of vitreous body	Disorders of vitreous body	2
5.15	Other eye disorders	Other eye disorders	3
5.16	Glaucoma	Glaucoma	3
5.17	Cataract	Cataract	3
5.18	Other retinal disorders	Other retinal disorders	3
5.19	Macular degeneration	Macular degeneration	2
5.20	Retinal detachments and defects	Retinal detach & defects	3
5.21	Blindness and visual disturbances	Blindness & visual disturb	3
5.22	Malignant neoplasm of eye	Malignant neoplasm of eye	1
6	Ear conditions	Ear Conditions	—
6.1	Otitis externa	Otitis externa	3
6.2	Wax in ear	Wax in ear	1
6.3	Open wound of ear	Open wound of ear	3
6.4	Other disorders of ear	Other disorders of ear	3
6.5	Otitis media	Otitis media	3
6.6	Disorders of tympanic membrane	Dsdr of tympanic membrane	3
6.7	Disorders of middle ear	Disorders of middle ear	3
6.8	Vertiginous syndromes	Vertiginous syndromes	3
6.9	Mastoiditis	Mastoiditis	3
6.10	Hearing loss	Hearing loss	3
6.11	Malignant neoplasm of middle ear	Malig neop of middle ear	1
7	Nose Conditions	Nose conditions	—
7.1	Rhinitis	Rhinitis	2
7.2	Sinusitis	Sinusitis	2
7.3	Other nasal disorders	Other nasal disorders	3
7.4	Deviated nasal septum	Deviated nasal septum	1
7.5	Nasal bone fracture	Nasal bone fracture	2
7.6	Malignant neoplasm of nasal cavities	Malig neop of nasal cavities	3
8	Mouth Conditions	Mouth Conditions	—
8.1	Cleft palate and lip	Cleft palate and lip	3
8.2	Congenital anomalies of oral cavity	Cong anomalies oral cavity	2
8.3	Congenital anomalies of face, jaw, skull	Cong anom face, jaw, skull	2
8.4	Disorders of teeth	Disorders of teeth	3
8.5	Open wound of face and mount	Open wound face & mouth	3
8.6	Anomalies of jaw size	Anomalies of jaw size	1
8.7	Other dentofacial anomalies	Other dentofacial anom	1
8.8	Gingival and periodontal diseases	Gingival & periodontal dz	2
8.9	Other disease of supporting structure	Other dz supporting struct	1
8.10	Temporomandibular joint disorder	TMJ disorder	1
8.11	Other dentofacial disorders	Other dentofacial disorders	3
8.12	Diseases of jaws	Diseases of jaws	2
8.13	Disease of salivary glands	Diseases of salivary glands	3
8.14	Diseases of oral soft tissue	Diseases of oral soft tissue	3
8.15	Benign neoplasm of oral cavity	Benign neop of oral cavity	2
8.16	Jaw fracture	Jaw fracture	3
8.17	Malignant neoplasm of oral cavity	Malig neop oral cavity	3
9	Respiratory Conditions	Respiratory Conditions	—
9.1	Upper respiratory infections	Upper respiratory infections	3
9.2	Diseases of upper respiratory tract	Dz upper respiratory tract	3
9.3	Lower respiratory diseases	Lower respiratory disease	3
9.4	Acute bronchitis	Acute bronchitis	2
9.5	Hypertrophy of tonsils and adenoids	Hypertrophy tonsils & aden	2
9.6	Congenital anomaly of respiratory system	Cong anon respire system	3
9.7	Pneumonia	Pneumonia	3
9.8	Disorders of lower respiratory tract	Dsdr of lower respir tract	1
9.9	Pleurisy	Pleurisy	2
9.10	Chronic bronchitis	Chronic bronchitis	2
9.11	Asthma	Asthma	3
9.12	Benign neoplasm of bronchus and lung	Benign neop bronchus & lung	3
9.13	Emphysema	Emphysema	2
9.14	Chronic obstructive pulmonary disease	COPD	1
9.15	Spontaneous pneumothorax	Spon pneumothorax	1
9.16	Lung transplant	Lung transplant	1
9.17	Malignant neoplasm of pharynx and larynx	Malig neop pharyn & laryn	2
9.18	Malignant neoplasm of pleura	Malig neop of pleura	2
9.19	Malignant neoplasm of bronchus and lung, active	Malig neop bron/lung, active	2
9.20	Malignant neoplasm of bronchus and lung, inactive	Malig neop bron/ling, inactive	2
10	Heart and Pulmonary Conditions	Heart and Pulmonary Cond	—
10.1	Abnormal heart beat	Abnormal heart beat	2
10.2	Hypertension	Hypertension	3
10.3	Congenital anomaly of circulatory system	Cong anom circulatory sys	3
10.4	Ventricular arrhythmias	Ventricular arrhythmias	3
10.5	Supraventricular arrhythmias	Supraventricular arrhythmias	3
10.6	Atrial septal defect	Atrial septal defect	2
10.7	Ventricular septal defect	Ventricular septal defect	2
10.8	Angina pectoris	Angina pectoris	1
10.9	Rheumatic fever	Rheumatic fever	2
10.10	Conduction disorders	Conduction disorders	3
10.11	Other heart disease	Other heart disease	3
10.12	Rheumatic heart disease	Rheumatic heart disease	2
10.13	Ischemic heart disease	Ischemic heart disease	3
10.14	Heart value disorders	Heart value disorders	3
10.15	Pulmonary heart disease	Pulmonary heart disease	3
10.16	Congestive heart failure	Congestive heart failure	2
10.17	Cardiomyopathy	Cardiomyopathy	2
10.18	Other aneurysm	Other aneurysm	3
10.19	Aortic aneurysm, initial	Aortic aneurysm, initial	2
10.20	Aortic aneurysm, follow-up	Aortic aneurysm, follow-up	2
10.21	Acute myocardial infarction, active	Acute myocardial infrct, active	2
10.22	Acute myocardial infarction, follow-up	Acute myocardial infct, fup	2
10.23	Heart transplant	Heart transplant	1
10.24	Malignant neoplasm of mediastinum	Malig neop of mediastinum	2
10.25	Malignant neoplasm of heart	Malig neoplasm of heart	1
11	Cerebrovascular and Artery Conditions	Cerebrovasc & Artery Cond	—
11.1	Pigmented nevus	Pigmented nevus	1
11.2	Superficial injury of head and neck	Superficial injury head & neck	2
11.3	Contusion of head and neck	Contusion of head and neck	1
11.4	Concussion	Concussion	3
11.5	Cerebral laceration	Cerebral laceration	3
11.6	Diseases of capillaries	Diseases of capillaries	1
11.7	Disorders of arteries	Disorders of arteries	3
11.8	Generalized arteriosclerosis	Generalized arteriosclerosis	3
11.9	Fracture of skull	Fracture of skull	3
11.10	Transient cerebral ischemia	Transient cerebral ischemia	3
11.11	Injury to blood vessels of head and neck	Inj to bl vessels head & neck	1
11.12	Occlusion of cerebral arteries	Occlusion of cerebral arteries	3
11.13	Cerebrovascular hemorrhage following injury	Cerebro hemorrhage, injury	3
11.14	Cerebrovascular hemorrhage	Cerebrovascular hemorrhage	2
12	Vein and Lymphatic Conditions	Vein & Lymphatic Cond	—
12.1	Anal fissure and fistula	Anal fissure and fistula	2
12.2	Hemorrhoids	Hemorrhoids	3
12.3	Other peripheral vascular diseases	Other peripheral vascular dz	3
12.4	Varicose veins of other sites	Varicose veins of other sites	3
12.5	Varicose veins of lower extremities	Varicose veins lower extreme	3
12.6	Thrombophlebitis	Thrombophlebitis	3
13	Digestive System Conditions	Digestive System Cond	—
13.1	Helicobacter pylori infection	Helicobacter pylori infection	1
13.2	Congenital anomaly of digestive system	Cong anom digestive system	1
13.3	Infectious diarrhea and gastroenteritis	Infect diarrhea/gastroenteritis	2
13.4	Other disorders of esophagus	Other disorders of esophagus	3
13.5	Gastritis and duodenitis	Gastritis and duodenitis	3
13.6	Gastroesophageal reflux	Gastroesophageal relux	1
13.7	Functional digestive disease	Functional digestive disease	2
13.8	Disorders of stomach and duodenum	Dsdr stomach & duodenum	3
13.9	Irritable colon	Irritable colon	1
13.10	Peptic ulcer	Peptic ulcer	3
13.11	Diverticula of intestine	Diverticula of intestine	3
13.12	Other diseases of intestine	Other diseases of intestine	3
13.13	Noninfectious gastroenteritis and colitis	Noninfect gastroent & colitis	3
13.14	Appendicitis	Appendicitis	3
13.15	Benign neoplasm of stomach	Benign neoplasm of stomach	2
13.16	Benign neoplasm of small intestine	Benign neoplasm small intestine	2
13.17	Benign neoplasm of colon and rectum	Benign neop colon/rectum	2
13.18	Intestinal obstruction	Intestinal obstruction	2
13.19	Vascular insufficiency of intestine	Vascular insufficiency intest	2
13.20	Crohn's disease	Crohn's disease	3
13.21	Gastrointestinal hemorrhage	Gastrointestinal hemorrhage	2
13.22	Intestine and pancreas transplant	Intest/pancreas transplant	1
13.23	Malignant neoplasm of anus and rectum, initial	Malig neop anus/rectum, initial	1
13.24	Malignant neoplasm of anus and rectum, active	Malig neop anus/rectum, active	1
13.25	Malignant neoplasm of anus and rectum, fup	Malig neop anus/rectum, fup	1
13.26	Malignant neoplasm of esophagus	Malig neop of esophagus	3
13.27	Malignant neoplasm of stomach	Malign neoplasm of stomach	1
13.28	Malignant neoplasm of small intestine	Malig neop of small intestines	2
13.29	Malignant neoplasm of peritoneum	malign neop of peritoneum	1
13.30	Malignant neoplasm of colon, initial	Malig neop of colon, initial	2
13.31	Malignant neoplasm of colon, active	Malig neop of colon, active	2
13.32	Malignant neoplasm of colon, follow up	Malig neop of colon, fup	2
14	Hernias	Hernias	—
14.1	Other hernia site	Other hernia site	3
14.2	Diaphragmatic hernia	Diaphragmatic hernia	3
14.3	External abdominal hernias	External abdominal hernias	3
15	Hepatobiliary System and Pancreas	Hepatobiliary Sys & Pancreas	—
15.1	Congenital anomaly of hepatobiliary system	Cong anom hepatobiliary sys	1
15.2	Other disorders of biliary tract	Other disorders of biliary tract	3
15.3	Cholecystitis	Cholecystitis	2
15.4	Cholelithiasis	Cholelithiasis	3
15.5	Benign neoplasm of liver and biliary passages	Benign neop liver/biliary pass	1
15.6	Other disorders of liver	Other disorders of liver	3
15.7	Hepatitis	Hepatitis	3
15.8	Benign neoplasm of pancreas	Benign neoplasm of pancreas	1
15.9	Diseases of pancreas	Diseases of pancreas	2
15.10	Chronic liver disease	Chronic liver disease	3
15.11	Liver transplant	Liver transplant	1
15.12	Malignant neoplasm of gallbladder	Malign neop of gallbladder	2
15.13	Malignant neoplasm of liver	Malignant neoplasm of liver	2
15.14	Malignant neoplasm of pancreas	Malig neop of pancreas	2
16	Thyroid Disorders	Thyroid Disorders	—
16.1	Other disorders of thyroid	Other disorders of thyroid	3
16.2	Goiter	Goiter	1
16.3	Hypothyroidism	Hypothyroidism	1
16.4	Hyperthyroidism	Hyperthyroidism	3
16.5	Malignant neoplasm of thyroid	Malignant neoplasm of thyroid	1
17	Diabetes Mellitus	Diabetes Mellitus	—
17.1	Diabetes mellitus with no complications	Diabetes w/no complications	1
17.2	Diabetes mellitus with ophthalmic manifestation	Diabetes with ophthalmic	3
17.3	Diabetes mellitus with neurologic manifestation	Diabetes with neurologic	3
17.4	Diabetes mellitus with circulatory manifestation	Diabetes with circulatory	3
17.5	Diabetes mellitus with renal manifestation	Diabetes with renal	3
17.6	Diabetes mellitus with multiple complications	Diabetes with multiple comp	3
18	Other Endocrine Disorders	Other Endocrine Disorders	—
18.1	Other endocrine disorders	Other Endocrine Disorders	3
18.2	Disorders of adrenal gland	Disorders of adrenal gland	2
18.3	Disorders of pituitary gland	Disorders of pituitary gland	3
18.4	Benign neoplasm of pituitary gland	Benign neop of pituitary gland	1
18.5	Malignant neoplasm of other endocrine glands	Malig neop other endo glands	2
18.6	Malignant neoplasm of thymus gland	Malig neop of thymus gland	1
18.7	Malignant neoplasm of pituitary gland	Malig neop of pituitary gland	1
18.8	Malignant neoplasm of adrenal gland	Malig neop of adrenal gland	1
19	Metabolic Disorders	Metabolic Disorders	—
19.1	Ill-defined metabolic symptoms	Ill-defined metabolic symptoms	1
19.2	Disorders of fluids and electrolytes	Dsdr of fluids and electrolytes	3
19.3	Nutritional deficiencies	Nutritional deficiencies	1
19.4	Disorders of lipid metabolism	Disorders of lipid metabolism	2
19.5	Gout	Gout	3
19.6	Other disorders of metabolism	Other disorders of metabolism	3
19.7	Cystic fibrosis	Cystic fibrosis	2
20	Immunity and Blood Disorders	Immunity & Blood disorders	—
20.1	Congenital anomaly of spleen	Congenital anomaly of spleen	1
20.2	Disease of blood forming organs	Dz of blood forming organs	1
20.3	Disease of white blood cells	Diseases of white blood cells	1
20.4	Anemia disorders	Anemia disorders	2
20.5	Aplastic anemias	Aplastic anemias	1
20.6	Thrombocytopenia	Thrombocytopenia	1
20.7	Other disorders of blood	Other disorders of blood	1
20.8	Disorders of immune mechanism	Dsdr of immune mechanism	3
20.9	Malignant neoplasm of spleen	Malignant neoplasm of spleen	1
21	Lymphatic and Hematopoietic Tissue	Lymph & Hematopoietic Tiss	—
21.1	Lymphadenitis	Lymphadenitis	1
21.2	Hemangioma	Hemangioma	2
21.3	Other malignant neoplasms of lymphoid tissue	Other malig neop lymph tissue	3
21.4	Burkitt's tumor	Burkitt's tumor	2
21.5	Lymphoma, active	Lymphoma, active	2
21.6	Lymphoma, inactive	Lymphoma, inactive	2
21.7	Hodgkin's disease, active	Hodgkin's disease, active	2
21.8	Hodgkin's disease, inactive	Hodgkin's disease, inactive	2
21.9	Sarcomas	Sarcomas	2
21.10	Leukemia, active	Leukemia, active	2
21.11	Leukemia, inactive	Leukemia, inactive	2
21.12	Multiple myeloma	Multiple myeloma	2
22	Urinary Tract and Kidney Conditions	Urinary Tract & Kidney Cond	—
22.1	Other disorders of urethra	Other disorders of urethra	2
22.2	Congenital anomalies of bladder and urethra	Cong anom bladder and urethra	2
22.3	Urinary tract infections	Urinary tract infections	2
22.4	Urethritis	Urethritis	2
22.5	Urethral stricture	Urethral stricture	2
22.6	Other disorders of bladder	Other disorders of bladder	3
22.7	Kidney infection	Kidney infection	3
22.8	Hydronephrosis	Hydronephrosis	1
22.9	Congenital anomalies of kidney and ureter	Cong anom kidney and ureter	3
22.10	Disorders of kidney and ureter	Disorders of kidney and ureter	3
22.11	Calculus of kidney and ureter	Calculus of kidney and ureter	2
22.12	Glomerulonephritis	Glomerulonephritis	3
22.13	Bladder transplant	Bladder transplant	1
22.14	Renal dialysis	Renal dialysis	1
22.15	Renal failure	Renal failure	2
22.16	Kidney transplant, initial	Kidney transplant, initial	1
22.17	Kidney transplant, follow-up	Kidney transplant, follow-up	1
22.18	Malignant neoplasm of bladder and urethra	Malig neop bladder and urethra	1
22.19	Malignant neoplasm of kidney and ureter	Malig neop kidney and ureter	1
23	Female Reproductive Conditions	Female Reproduction Cond	—
23.1	Disorders of cervix and vagina	Disorders of cervix and vagina	3
23.2	Cervicitis and vaginitis	Cervicitis and vaginitis	2
23.3	Uterovaginal prolapse	Uterovaginal prolapse	3
23.4	Other disorders of uterus	Other disorders of uterus	3
23.5	Other disorders of female genital organs	Other dsdr female genital org	3
23.6	Ovarian dysfunction	Ovarian dysfunction	3
23.7	Menstrual disorders	Menstrual disorders	2
23.8	Menopausal symptoms	Menstrual disorders	1
23.9	Benign neoplasm of uterus	Benign neoplasm of uterus	2
23.10	Endometriosis	Endometriosis	2
23.11	Ovarian cyst	Ovarian cyst	1
23.12	Carcinoma in situ of cervix	Carcinoma in situ of cervix	1
23.13	Malignant neoplasm of placenta	Malig neop of placenta	1
23.14	Malignant neoplasm of cervix and vagina	Malig neop of cervix & vagina	2
23.15	Malignant neoplasm of ovary and fallopian tube	Malig neop ovary & fallop tube	1
23.16	Malignant neoplasm of uterus	Malignant neoplasm of uterus	1
24	Male Reproductive Conditions	Male Reproductive Cond	—
24.1	Hydrocele	Hydrocele	2
24.2	Orchitis and epididymitis	Orchitis and epididymitis	2
24.3	Disorders of male genital organs	Dsdr of male genital organs	3
24.4	Disorders of penis	Disorders of penis	2
24.5	Other disorders of prostate	Other disorders of prostate	3
24.6	Prostatic hypertrophy and prostatitis	Prostatic hyertro & prostatitis	2
24.7	Malignant neoplasm of other male genital organs	Malig neop other male gen org	3
24.8	Malignant neoplasm of testis	Malignant neoplasm of testis	1
24.9	Malignant neoplasm of prostate, active	Malig neop of prostate, active	1
24.10	Malignant neoplasm of prostate, inactive	Malig neop of prostate, inactive	1
25	Infertility Treatment	Infertility Treatment	—
25.1	Contraceptive management	Contraceptive management	1
25.2	Infertility female	Infertility female	2
25.3	Procreative management	Procreative management	1
25.4	Infertility male	Infertility male	1
26	Maternity-Related Conditions	Maternity-Related Cond	—
26.1	Abnormal product of conception	Abnorm product of conception	1
26.2	Ectopic pregnancy	Ectopic pregnancy	2
26.3	Spontaneous and induced abortions	Spont and induced abortions	1
26.4	Single newborn, normal pregnancy	Single newborn, normal	1
26.5	Single newborn, complicated pregnancy	Single newborn, complicated	3
26.6	Multiple newborns, normal pregnancy	Multiple newborns, normal	1
26.7	Multiple newborns, complicated pregnancy	Multiple newborns, complic	3
26.8	Other obstetrical care	Other obstetrical care	1
26.9	Completely normal delivery	Completely normal delivery	1
26.10	Multiple gestation	Multiple gestation	1
26.11	Complications before birth	Complications before birth	3
26.12	Complications of delivery	Complications of delivery	3
27	Neonatal Conditions	Neonatal Conditions	—
27.1	Other minor neonatal conditions	Minor neonatal conditions	3
27.2	Perinatal jaundice	Perinatal jaundice	3
27.3	Other major neonatal conditions	Major neonatal conditions	3
27.4	Respiratory distress syndrome	Respiratory distress syndrome	1
27.5	Disorders due to short gestation	Disorders to short gestation	3
28	Congenital Anomalies	Congenital Anomalies	—
28.1	Congenital anomalies of sense organs	Cong anom of sense organs	3
28.2	Congenital endocrine and metabolic anomaly	Cong endo/metabolic anom	1
28.3	Congenital reproductive system anomaly	Cong reproductive sys anom	1
28.4	Other chromosomal anomaly	Other chromosomal anomaly	1
28.5	Down's syndrome	Down's syndrome	1
29	Skin and Subcutaneous Tissue Conditions	Skin & Subcutaneous Tissue	—
29.1	Ill-defined integument symptoms	Ill-defined integument sym	1
29.2	Congenital anomalies of skin	Congenital anomalies of skin	1
29.3	Congenital integument anomaly	Cong integument anom	1
29.4	Other infections of skin and subcutaneous tissue	Other inf skin/subcutan tissue	2
29.5	Other disorders of skin and subcutaneous tissue	Other dsdr skin/subcutan tiss	3
29.6	Skin keratoses	Skin keratoses	2
29.7	Impetigo	Impetigo	1
29.8	Urticaria	Urticaria	1
29.9	Dermatitis and eczema	Dermatitis and eczema	2
29.10	Cellulites and abscess, finger and toe	Cellul & abscess, finger/toe	2
29.11	Cellulites and abscess, leg and buttock	Cellul & abscess, leg/buttock	1
29.12	Cellulites and abscess, other site	Cellul & abscess, other site	1
29.13	Rosacea	Rosacea	1
29.14	Dermatophytoses	Dermatophytoses	2
29.15	Sebaceous cyst	Sebaceous cyst	1
29.16	Pilonidal cyst	Pilonidal cyst	2
29.17	Acne	Acne	1
29.18	Lipoma	Lipoma	2
29.19	Benign neoplasm of skin	Benign neoplasm of skin	1
29.20	Diseases of nail, excluding infections	Dz of nail, excluding infections	1
29.21	Diseases of hair and hair follicles	Dz of hair and hair follicles	2
29.22	Erythematous condition	Erythematous condition	2
29.23	Psoriasis and pityriasis	Psoriasis and pityriasis	2
29.24	Carcinoma in situ of skin	Carcinoma in situ of skin	1
29.25	Chronic skin ulcer	Chronic skin ulcer	2
29.26	Other malignancy of skin	Other malignancy of skin	2
29.27	Kaposi's sarcoma	Kaposi's sarcoma	3
29.28	Malignant melanoma of skin, initial	Malig melanoma of skin, initial	2
29.29	Malignant melanoma of skin, active	Malig melanoma of skin, active	2
29.30	Malignant melanoma of skin, follow up	Malig melanoma of skin, fup	2
30	Breast Conditions	Breast Conditions	—
30.1	Inflammatory disease of breast	Inflammatory disease of breast	2
30.2	Cystic breast disease	Cystic breast disease	2
30.3	Benign neoplasm of breast	Benign neoplasm of breast	1
30.4	Carcinoma in situ of breast, initial	Carc in situ of breast, initial	1
30.5	Carcinoma in situ of breast, active	Carc in situ of breast, active	1
30.6	Carcinoma in situ of breast, follow-up	Carc in situ of breast, fup	1
30.7	Malignant neoplasm of breast skin	Malig neop of breast skin	1
30.8	Malignant neoplasms of breast, initial	Malig neop of breast, initial	2
30.9	Malignant neoplasm of breast, active	Malig neop of breast, active	2
30.10	Malignant neoplasm of breast, follow-up	Malig neop of breast, fup	2
31	Musculoskeletal Conditions	Musculoskeletal Conditions	—
31.1	Congenital musculoskeletal anomaly	Cong musculoskel anomaly	1
31.2	Congenital anomalies of spine	Congenital anomalies of spine	3
31.3	Other arthropathy disorders	Other arthropathy disorders	3
31.4	Bursitis	Bursitis	3
31.5	Other disorders of bone and cartilage	Other dsdr bone & cartilage	3
31.6	Nonallopathic lesions	Nonallopathic lesions	2
31.7	Bone transplant	Bone transplant	1
31.8	Cervical spine pain	Cervical spine pain	3
31.9	Low back pain	Low back pain	3
31.10	Other acquired deformity	Other acquired deformity	2
31.11	Other curvature of spine	Other curvature of spine	2
31.12	Scoliosis	Scoliosis	1
31.13	Minor injury of trunk	Minor injury of trunk	1
31.14	Osteoporosis	Osteoporosis	1
31.15	Benign neoplasm of skull and trunk bones	Benign neop skull/trunk bones	1
31.16	Other osteochondropathies	Other osteochondropathies	1
31.17	Osteomyelitis	Osteomyelitis	3
31.18	Diffuse connective tissue disorders	Diffuse connective tiss dsdr	1
31.19	Rheumatoid arthritis	Rheumatoid arthritis	3
31.20	Dislocation of vertebra	Dislocation of vertebra	3
31.21	Fracture of vertebra	Fracture of vertebra	3
31.22	Major injury of trunk	Major injury of trunk	1
31.23	Traumatic pneumothorax	Traumatic pneumothorax	3
31.24	Crushing injury of trunk	Crushing injury of trunk	2
31.25	Malignant neoplasm of skull and trunk bones	Malig neop skull/trunk bones	1
32	Upper Limb Conditions	Upper Limb Conditions	—
32.1	Contusion of upper limb	Contusion of upper limb	2
32.2	Sprain/strain of wrist and finger	Sprain/strain of wrist & finger	2
32.3	Sprain/strain of upper arm	Sprain/strain of upper arm	2
32.4	Sprain/strain of lower arm	Sprain/strain of lower arm	2
32.5	Open wound of hand and fingers	Open wound hand & fingers	3
32.6	Open wound of arm	Open wound of arm	3
32.7	Dislocation of finger and wrist	Dislocation of finger and wrist	3
32.8	Dislocation of upper arm	Dislocation of upper arm	3
32.9	Congenital deformities of upper limb	Cong deformities upper limb	3
32.10	Benign neoplasm of upper limb	Benign neop of upper limb	1
32.11	Fracture of hand bones	Fracture of hand bones	3
32.12	Amputation of finger	Amputation of finger	2
32.13	Fracture of radius and ulna	Fracture of radius and ulna	3
32.14	Fracture of humerus	Fracture of humerus	3
32.15	Fracture of clavicle and scapula	Fracture of clavicle/scapula	3
32.16	Amputation of hand and arm	Amputation of hand and arm	3
32.17	Crushing injury of upper limb	Crushing injury of upper limb	3
32.18	Malignant neoplasm of upper limb	Malig neop of upper limb	1
33	Lower Limb Conditions	Lower Limb Conditions	—
33.1	Contusion of lower limb	Contusion of lower limb	2
33.2	Sprain/strain of foot and ankle	Sprain/strain of foot and ankle	2
33.3	Sprain/strain of leg	Sprain/strain of leg	3
33.4	Sprain/strain of hip and thigh	Sprain/strain of hip and thigh	1
33.5	Open wound of foot and toes	Open wound of foot and toes	3
33.6	Open wound of leg	Open wound of leg	3
33.7	Open wound of hip and thigh	Open wound of hip and thigh	3
33.8	Dislocation of foot and ankle	Dislocation of foot and ankle	3
33.9	Dislocation of knee	dislocation of knee	2
33.10	Dislocation of hip	Dislocation of hip	3
33.11	Congenital deformities of lower limb	Cong deformities lower limb	3
33.12	Joint replacement	Joint replacement	1
33.13	Benign neoplasm of lower limb	Benign neop of lower limb	1
33.14	Hammer toe	Hammer toe	3
33.15	Degenerative joint disease	Degenerative joint disease	2
33.16	Fracture of foot bones	Fracture of foot bones	3
33.17	Fracture of ankle	Fracture of ankle	3
33.18	Fracture of patella	Fracture of patella	2
33.19	Fracture of tibia and fibula	Fracture of tibia and fibula	3
33.20	Amputation of toes	Amputation of toes	2
33.21	Other joint derangement	Other joint derangement	3
33.22	Derangement of knee	Derangement of knee	3
33.23	Fracture of femur	Fracture of femur	3
33.24	Amputation of foot and leg	Amputation of foot and leg	3
33.25	Crushing injury of lower limb	Crushing injury of lower limb	3
33.26	Malignant neoplasm of lower limb	Malig neoplasm of lower limb	1
34	Mental Disorders	Mental Disorders	—
34.1	Other nonpsychotic disorders	Other nonpsychotic disorders	3
34.2	Psychogenic conditions	Psychogenic conditions	3
34.3	Sleep walking	Sleep walking	1
34.4	Hypersomnia	Hypersomnia	1
34.5	Insomnia	Insomnia	2
34.6	Other neurotic disorders	Other neurotic disorders	1
34.7	Maltreatment syndrome	Maltreatment syndrome	1
34.8	Sexual deviations	Sexual deviations	1
34.9	Tics and repetitive movements	Tics and repetitive movements	3
34.10	Hysteria	Hysteria	3
34.11	Delays in metal development	Delays in mental development	2
34.12	Phobic disorders	Phobic disorders	2
34.13	Anxiety disorders	Anxiety discords	2
34.14	Personality and disturbance disorder	Personality & disturb dsdr	3
34.15	Other nonorganic psychoses	Other nonorganic psychoses	1
34.16	Other eating disorders	Other eating disorders	1
34.17	Nonpsychotic depression	Nonpsychotic depression	2
34.18	Obsessive-compulsive disorders	Obsessive-compulsive dsdr	1
34.19	Paranoid states	Paranoid states	2
34.20	Sleep apnea	Sleep apnea	1
34.21	Major depression	Major depression	3
34.22	Mental retardation	Mental retardation	2
34.23	Manic depression	Manic depression	3
34.24	Bipolar depression	Bipolar depression	3
34.25	Bulimia	Bulimia	1
34.26	Anorexia nervosa	Anorexia nervosa	1
34.27	Autism	Autism	1
34.28	Narcolepsy	Narcolepsy	1
34.29	Alcohol dependence	Alcohol dependence	3
34.30	Drug dependence	Drug dependence	3
34.31	Organic dementias	Organic dementias	3
34.32	Schizophrenia	Schizophrenia	3
34.33	Alzheimer's disease	Alzheimer's disease	1
35	Burns	Burns	—
35.1	Burn of upper limb	Burn of upper limb	3
35.2	Burn of lower limb	Burn of lower limb	3
35.3	Burns of head and neck	Burns of head and neck	3
35.4	Burn of trunk	Burn of trunk	3
35.5	Burn of multiple sites	Burn of multiple sites	3
36	Other Medical Conditions	Other Medical Conditions	—
36.1	Complication of surgery	Complication of surgery	1
36.2	Complication of genitourinary procedure	Complic genitourin procedure	1
36.3	Complication of orthopedic procedure	Complic orthopedic procedure	1
36.4	Complication of gastrointestinal procedure	Complic gastrointestinal proc	1
36.5	Complication of respiratory procedure	Complic respiratory procedure	1
36.6	Complications of trauma	Complications of trauma	1
36.7	Complication of nervous system procedure	Complic nervous sys proc	1
36.8	Complication of vascular procedure	Complic vascular procedure	1
36.9	Complication of transplant	Complication of transplant	1
36.10	Effects of external causes	Effects of external causes	1
36.11	Poisoning by medicines	Poisoning by medicines	1
36.12	Toxic effects of substances	Toxic effects of substances	1
36.13	Personal assaults	Personal assaults	1
36.14	Motor vehicle accident	Motor vehicle accident	1
36.15	General presenting symptoms	General presenting symptoms	1
36.16	Non-specific exanthem	Non-specific exanthem	1
36.17	Abdominal pain	Abdominal pain	1
36.18	Dyspnea	Dyspnea	2
36.19	Chest pain	Chest pain	1
36.20	Non-newborn jaundice	Non-newborn jaundice	1
36.21	Non-newborn cyanosis	Non-newborn cyanosis	1
36.22	Shock	Shock	1
36.23	Spleenomegaly	Spleenomegaly	1
36.24	Hepatomegaly	Hepatomegaly	1
36.25	Coma and stupor	Coma stupor	1
36.26	Gangrene	Gangrene	1
37	Replaced Diagnosis Codes	Replaced Diagnosis Codes	—
37.1	Replaced non-specific diagnosis codes	Replaced non-specific dx code	1

An embodiment of the present invention forms longitudinal episodes of care for a patient using medical claims data. A longitudinal episode of care is defined as all services linked together that are used to treat a patient's medical condition within a specified period of time, including all ambulatory, outpatient, inpatient, and prescription drug experience. This linkage allows examination of a physician's (or a physician group's) global patterns of treatment for a patient with a specific condition, such as diabetes and arthritis. The longitudinal episode of care may also be used in patient disease management, patient health promotion and wellness, and many other healthcare programs.

[0111] The specified time period, or window period, is based on the maximum number of days between contact with a provider for which follow-up care is still reasonable. Each of the medical conditions has its unique window period. If the date of service for a patient's episode is separated by a longer period than the window period, the latest date of service considered the start date for a new condition-specific episode of care.

[0112] For example, the window period for Medical Condition 9.1-upper respiratory infections is 60 days. Assume that a patient had three treatments in January and two in the following August. Because the treatments in the series were separated by more than 60 days, these would be two episodes of care. Table 11 gives the window periods for medical conditions in PMC Group 9-Respiratory Conditions.

[0113]

TABLE 11
Medical Condition Window Periods
for PMC Group 9-Respiratory Conditions
Medical
Condition	Medical Condition	Window
Number	Long Description	Periods
6	Ear conditions	—
6.1	Otitis externa	90
6.2	Wax in ear	60
6.3	Open wound of ear	90
6.4	Other disorders of ear	90
6.5	Otitis media	90
6.6	Disorders of tympanic	120
	membrane
6.7	Disorders of middle ear	120
6.8	Vertiginous syndromes	180
6.9	Mastoiditis	180
6.10	Hearing loss	365
6.11	Malignant neoplasm of middle	365
	ear

Step 100: Form Inpatient Encounters and Assign Diagnosis

[0114] The Grouper function first checks professional service CLIs for inpatient facility place of service to identify potential inpatient encounters. A professional service includes the Types of Service of visits, lab/path services, medical and surgical procedures, and diagnostic tests. All facility charges and prescription drugs are excluded from professional services. The professional services occur in a Place of Service of hospital inpatient.

[0115] The identification of a professional service that starts a potential inpatient encounter is called a trigger event.

[0116] The rule associates with the potential inpatient encounter all services that occurred on the dates following the trigger event. Services continue to be counted until an end date is reached. The end date is identified when there is a two-day gap in professional charges. At this point the potential encounter ends. For example, if one CLI ends on a Monday and the next CLI begins on Wednesday, then the two CLIs could be part of a single inpatient encounter because only one day (Tuesday) separates them. If the second CLI begins on Thursday, then it would be part of a separate inpatient encounter because two days (Tuesday and Wednesday) separate it from the first CLI.

[0117] The rule then looks at all professional service charges associated with the potential inpatient encounter to determine whether they total $350 or more. If the professional service charges total $350 or more, the rule concludes that we have identified an eligible inpatient encounter. Experience shows that charges should almost always be over this minimum threshold level. The minimum threshold level is subject to change over time.

[0118] For inpatient encounters with professional service charges of $350 or more, the rule assigns a diagnosis code to all CLIs associated with the encounter. To assign the appropriate diagnosis code, all professional service CLIs associated with the encounter are identified. The rule then temporarily assigns these professional service CLIs to one of 526 medical conditions. Using these temporary assignments, the rule adds up all charges by medical condition. The medical condition with the highest charge amount is then assigned as the medical condition for the entire encounter, and all CLIs associated with the encounter receive diagnosis codes appropriate for that medical condition.

[0119] The rule uses professional charges to identify the start and end dates of a hospital inpatient encounter. Facility services (i.e., room and board service and ancillary services) are assigned to the ongoing encounter using these start and end dates.

Step 120: Drop Inpatient Encounters without Minimal Professional Charges

[0120] If the overall professional service charges associated with the potential encounter do not reach $350, then an eligible inpatient encounter has not been identified. For example, consider a cardiac stress test that includes physician charges of $250 marked with inpatient facility as the place of service and a facility-related component of $300. Broken down in this way, we can see that the medical charges (non-facility and drug charges) do not meet the $350 threshold, and the potential encounter would not be regarded as an eligible inpatient encounter. When the potential encounter does not meet the $350 threshold, all CLIs associated with the potential inpatient encounter are released and will be examined as described in the next step.

Step 130: Form Outpatient Encounters and Assign Diagnosis

[0121] To identify outpatient facility encounters, the Grouper function examines all professional service CLIs except those already assigned to an inpatient facility encounter. The rule looks for professional service CLIs that have a Place of Service of inpatient hospital, emergency room, urgent care, outpatient facility, surgicenter, or birthing center as the place of service. At this point in the process, the professional service CLIs with a Place of Service of inpatient hospital did not meet the minimum hospital inpatient encounter criteria. These CLIs are now examined for a possible outpatient facility encounter.

[0122] The identification of a professional service that starts a potential outpatient encounter is called a trigger event. CLIs with Provider Type services that include only laboratory and durable medical equipment do not trigger a potential outpatient encounter.

[0123] Once a potential outpatient encounter has been identified, the rule inspects all CLIs that occurred on the date of the potential encounter to determine whether total charges equal or exceed $100. If so, then the rule concludes that an eligible outpatient encounter has been identified. Experience shows that charges should almost always be over this minimum threshold level. The minimum threshold level is subject to change over time.

[0124] For outpatient encounters with total charges of $100 or more, the rule assigns a diagnosis code to all CLIs associated with the encounter. To assign the appropriate diagnosis code, all professional service CLIs associated with the encounter are identified. The rule then temporarily assigns these professional service CLIs to one of 526 medical conditions. Using these temporary assignments, the rule adds up all charges by medical condition. The medical condition with the highest charge amount is then assigned as the medical condition for the entire encounter, and all CLIs associated with the encounter receive diagnosis codes appropriate for that medical condition.

Step 140: Drop Outpatient Encounters without Minimal Total Charges

[0125] If the total charges are less than $100, the rule concludes that that we have not identified an actual outpatient encounter. For example, many labs are performed in outpatient hospital facilities. This analysis helps ensure that lab-only events are not included as outpatient encounter.

[0126] CLIs associated with potential outpatient encounters that do not meet the $100 threshold may still be associated with medical condition episodes. They are released and through subsequent analysis may be assigned to the following service categories: Professional Visits, Diagnostic Tests, Laboratory and Pathology, Medical and Surgical Procedures, Prescription Drugs, Alternative Sites, or Other Medical Services.

[0127] Facility CLIs not associated with actual inpatient or outpatient encounters are assigned to other medical care service categories based primarily on the procedure code that may be present on the CLI. For example, if the procedure code indicates chemotherapy, it would be assigned to the service category Other Medical Services as part of the sub-service category Chemo/Radiology. If no explanatory procedure code is present, the facility CLI will be categorized under the service category Other Medical Services as part of the sub-service category Other Medical Care.

Step 150: Ill-Defined Diagnosis Code Rule

[0128] A patient's medical service will appear in an episode of care if the claim line item (CLI) has a valid and “defined” assigned ICD.9 code. For example, defined codes include ICD.9 codes such as 250.0 (diabetes without mention of complication), 244.3 (iatrogenic hypothyroidism), and 370.20 (superficial keratitis).

[0129] However, up to 40% of all CLIs may have “ill-defined” assigned ICD.9 codes. Ill-defined means that either the ICD.9 codes are either missing or nonspecific ICD.9 codes. Nonspecific codes include ICD.9 codes such as 780.9 (other general symptoms), 796.4 (other abnormal clinical findings), and 799 (other ill-defined causes of morbidity). Non-specific codes are treated as if the ICD.9 code on the CLI is missing. The CLI remains, but the ill-defined value on the CLI is ignored. Ill-defined ICD.9 coding falls into medical condition 37.1.

[0130] To prevent under-reporting of utilization within an episode of care, a defined ICD.9 code is assigned to CLIs with ill-defined ICD.9 codes. Consequently, the Ill-Defined Diagnosis Code Rule assigns a diagnosis code to each CLI with an ill-defined code as follows.

[0131] The Grouper function first looks for an appropriate diagnosis during the two days before and after the non-specific diagnosis code date. For example, assume a CLI has a non-specific diagnosis code on March 17. The rule looks backwards two days until March 15 for a valid and accurate diagnosis code. If no defined diagnosis code is found, then the rule looks two days forward until March 19 for a valid accurate diagnosis code. If no appropriate diagnosis is found, the rule then examines the five days before and after. If no appropriate diagnosis is found, the rule then examines the nine days before. In an embodiment, nine days forward in time can be examined and day period durations and number can be changed.

[0132] Moreover, the expected resource intensity level of each of 526 medical conditions is considered. If there are two separate CLIs on a given day that have a defined ICD.9 code, the rule assigns the diagnosis code of the more resource-intensive medical condition to the CLI with an ill-defined code. For example, if there is a diagnosis code for diabetes on February 15 and also a diagnosis code for upper respiratory tract infection on February 15, then diabetes will be assigned because it is more resource intensive. So, if there are two CLIs on the same day with different ICD.9 codes in the primary position field, then the most resource intensive diagnosis code is assigned during the two day look-back assignment process, during the two day look-forward assignment process, and so forth.

[0133] Table N shows the resource intensity rank order assigned to different medical conditions. The lower the resource intensity rank number for a medical condition, the higher the expected need for medical care services as compared to medical conditions with higher resource intensity rank numbers.

[0134]

TABLE N
Resource Intensity Rank Order for Medical Conditions
Medical		Resource
Condition	Medical Condition	Intensity
Number	Long Description	Rank
6	Ear Conditions	—
6.1	Otitis externa	464
6.2	Wax in ear	459
6.3	Open wound of ear	457
6.4	Other disorders of ear	455
6.5	Otitis media	454
6.6	Disorders of tympanic membrane	450
6.7	Disorders of middle ear	449
6.8	Vertiginous syndromes	440
6.9	Mastoiditis	436
6.10	Hearing loss	192
6.11	Malignant neoplasm of middle ear	84
22	Urinary Tract and Kidney Conditions	—
22.1	Other disorders of urethra	428
22.2	Congenital anomalies of bladder and urethra	413
22.3	Urinary tract infections	412
22.4	Urethritis	411
22.5	Urethral stricture	410
22.6	Other disorders of bladder	397
22.7	Kidney infection	396
22.8	Hydronephrosis	335
22.9	Congenital anomalies of kidney and ureter	334
22.10	Disorders of kidney and ureter	140
22.11	Calculus of kidney and ureter	132
22.12	Glomerulonephritis	130
22.13	Bladder transplant	57
22.14	Renal dialysis	49
22.15	Renal failure	50
22.16	Kidney transplant, initial	46
22.17	Kidney transplant, follow-up	Not applicable
22.18	Malignant neoplasm of bladder and urethra	25
22.19	Malignant neoplasm of kidney and ureter	20

[0135] If a CLI has not been assigned to a valid ICD.9 code at this point, then the CLI will not be assigned to an episode of care at this point in time.

[0136] Prescription drug CLIs generally do not have an ICD.9 diagnosis code assigned. An embodiment of the present invention assigns a defined ICD.9 diagnosis code to each prescription drug CLI by applying the same Ill-Defined Diagnosis Code Rule as for any other service category that has an ill-defined ICD.9 code.

Step 160: Trigger Episode of Care Building

[0137] A Grouper function treats the start and end points for chronic and acute episodes differently. For chronic conditions (e.g., diabetes, asthma, ischemic heart disease), an episode of care begins when a CLI is initially found during the study period that has a defined ICD.9 code that has been assigned to that medical condition. Then, chronic conditions may continue on indefinitely as recognized by the window period of 365 days (refer to Table 11 for chronic disease window periods of 365 days).

[0138] However, for the purposes of physician efficiency analysis, chronic conditions are considered to be 180-day duration. Therefore, a chronic condition ends 180 days after identifying the first CLI with a diagnosis (defined ICD.9 code) for the specific chronic condition. The rule determines that the patient is present for 180 days during the study period after the first CLI with a diagnosis for the specific chronic condition. Moreover, in the physician efficiency analysis, all chronic conditions included in the analysis must start before the last day of the first half of the study period and must have a 180-day duration. The embodiment recognizes that this maximum allowable duration may be varied.

[0139] For acute conditions (e.g., upper respiratory infections, otitis media, conjunctivitis), an episode of care begins when a CLI is initially found during the study period that has a defined ICD.9 code that has been assigned to that medical condition.

[0140] For acute conditions, the patient's episode duration directly relates to the process of care. The process of care is identified using window periods for each medical condition. A medical condition's window period is based on the maximum number of days between contact with a provider for which follow-up care is still reasonable. Each medical condition has its own unique window period as presented for select medical conditions in Table 11. If the date of service for a patient's episode is separated from the previous date of service by a period longer than the window period for that condition, the latest date of service is considered the start date for a new condition-specific episode of care.

[0141] For example, upper respiratory infections generally last up to 30 days. The window period is made about 1.5-to-2.5 times as long as the expected average longer duration episodes for a medical condition to ensure episode completion. Therefore, the window period for upper respiratory infections is about 60 days. Acute condition episodes are considered complete (or end) if an amount of time (equal to the window period) elapses in which no ICD.9 codes for that condition are present.

[0142] Continuing our upper respiratory infection example, assume that a patient had three treatments for upper respiratory infection in January and two in the following August. The window period for upper respiratory infections is 60 days. Because the two groups of treatments were separated by more than 60 days, they would be considered two separate episodes of care. In the physician efficiency analysis, the maximum allowable duration for any acute condition is 180 days. The embodiment recognizes that this maximum allowable duration may be varied.

Step 170: Apply Rank Order Rule

[0143] After the triggering episode of care building rule, the rank order rule assigns claims that continue to have ill-defined diagnosis codes (e.g., missing or non-specific ICD.9 codes) to the highest resource-intensity ranked ongoing episode for a patient. Table N presents the resource intensity rank order for select medical conditions.

[0144] After the rank order rule, generally more than 98% of CLIs receive a defined ICD.9 code, and are assigned to one of the patient's ongoing condition-specific episodes of care. However, the percent ranges generally from 85% to 99% of CLIs that receive a defined ICD.9 code, depending on the accuracy of original ICD.9 coding in the particular medical claims data file of being examined.

Step 180: Apply CLI Day Rule

[0145] The Grouper function next examines the more resource-intensive medical condition episodes to ensure an appropriate number of CLIs are present within the episode of care. This is to ensure that no episodes are built because of a single CLI ICD.9 miscoding by a physician.

[0146] Most episodes, after being built, are eligible using the requirement that only one CLI is present with a condition-specific ICD.9 diagnosis code. For example, Table 12 shows that only one CLI with an ICD.9 code is required for conditions such as neuritis, headaches, conjunctivitis, otitis media, sinusitis, and upper respiratory infections.

[0147] However, some episodes, after being built, are eligible using the requirement that a CLI with a condition-specific ICD.9 code must be present on two different days. These are episodes of medical conditions that can be expected to last more than one day. For instance, the one CLI on two different days rule is required for conditions such as myoneural disorder, multiple sclerosis, pneumothorax, pneumocystosis, fracture of skull, intestinal obstruction, hepatitis, fracture of vertebra, and deep burns.

[0148] Other episodes, after being built, are eligible using the requirement that a CLI with a condition-specific ICD.9 code must be present on three different days. These episodes are more chronic by nature and require more resource intensive treatment. For example, the one CLI on three different days rule used for conditions such as injury of the spinal column, malignant neoplasm of nasal cavities, malignant neoplasm of lung, cerebrovascular hemorrhage, malignant neoplasm of pancreas, and renal failure.

[0149] If the built episode does not meet the required eligibility criteria, then the CLIs in the episode are released and through subsequent analysis, may be assigned to another of the patient's ongoing episodes of care. The diagnosis coding on the released CLIs is treated the same way as if the ICD.9 code were “ill-defined.”

[0150]

TABLE 12
Claim Line Item (CLI) Day Rule Table
		CLI
Medical Condition	Medical Condition	Day
Number	Long Description	Rule
6	Ear Conditions	—
6.1	Otitis externa	1
6.2	Wax in ear	1
6.3	Open wound of ear	1
6.4	Other disorders of ear	1
6.5	Otitis media	1
6.6	Disorders of tympanic membrane	1
6.7	Disorders of middle ear	1
6.8	Vertiginous syndromes	1
6.9	Mastoiditis	1
6.10	Hearing loss	1
6.11	Malignant neoplasm of middle ear	3
16	Thyroid Disorders	—
16.1	Other disorders of thyroid	1
16.2	Goiter	1
16.3	Hypothyroidism	1
16.4	Hyperthyroidism	2
16.5	Malignant neoplasm of thyroid	3
22	Urinary Tract and Kidney Conditions	—
22.5	Urethral stricture	1
22.6	Other disorders of bladder	1
22.7	Kidney infection	1
22.8	Hydronephrosis	1
22.9	Congenital anomalies of kidney and ureter	1
22.10	Disorders of kidney and ureter	1
22.11	Calculus of kidney and ureter	1
22.12	Glomerulonephritis	1
22.13	Bladder transplant	3
22.14	Renal dialysis	3
22.15	Renal failure	3
22.16	Kidney transplant, initial	3
22.17	Kidney transplant, follow-up	3
22.18	Malignant neoplasm of bladder and urethra	3
22.19	Malignant neoplasm of kidney and ureter	3

Step 190: Apply Rank Order Rule

[0151] After the CLI day rule, the rank order rule is reapplied in an attempt to assign CLIs, which were released during the CLI day rule, a defined diagnosis code as defined under Step 170. The ill-defined CLIs are assigned to the highest resource-intensity ranked ongoing episode for a patient that has passed the CLI day rule.

Step 200: Severity-of-Illness Assignment Rule

[0152] Each patient's condition-specific episode is labeled with a severity-of-illness marker to reduce the heterogeneity of episodes within a medical condition. Severity-of-illness is defined as the probability of loss of function due to the physiologic progression or impact of the medical condition. Under this definition, the Grouper function uses only ICD.9 diagnosis codes to assign a patient's episode with a severity-of-illness marker. The Grouper function does not define severity-of-illness by resource utilization within the patient's condition-specific episode (such as whether a surgery or a resource-intensive diagnostic test was present in the patient's episode of care).

[0153] There are up to three (3) severity-of-illness (SOI) classes for each of the 526 medical conditions, with SOI-1 being the least severe (routine, noncomplicated) and SOI-3 being the most severe. However, the embodiment recognizes that there may be a differing number of SOT classes. Some medical conditions have only one or two severity-of-illness levels. Refer to the fourth column in Table 10, List of Medical Conditions in the Grouper function.

[0154] The severity-of-illness assignment rule operates to increase the SOI class on a patient's medical condition episode on the basis of two main criteria: (1) the ICD.9 codes that are present on the CLIs in each episode with respect to SOI class; and (2) the number of CLIs with ICD.9 codes in the more severe SOI classes.

[0155] With respect to the first criterion, Table 13 shows the selected diagnosis (ICD.9) codes listed in Table M stratified by SOI class. The ICD.9 codes within each SOI class are stratified based on the probability of loss of function due to the physiologic progression of the medical condition. A patient's episode may receive a more severe SOI ranking only if CLIs within the episode have ICD.9 coding present in the more severe SOI classes. For each medical condition episode of care, the severity-of-illness assignment rule accesses this table and determines whether the appropriate ICD.9 coding is present for a potential increase in SOI ranking.

[0156]

TABLE 13
Selected Diagnosis (ICD.9) Codes by Medical Condition and
Severity-of-Illness Level
Medical		Number of
Condition	Medical Condition	Severity	SOI-1	SOI-2	SOI-3
Number	Long Description	Classes	Class	Class	Class
5.2	Conjunctivitis	2	077.0	372.1	—
			077.8	372.14
			372.0	372.22
			372.01
6.5	Otitis media	3	381	381.20	382.01
			381.02	382	382.1
			381.06	382.00
				382.4
7.2	Sinusitis	2	461.0	473	—
			461.2	473.2
			461.3	473.3
9.11	Asthma	3	493.0	493.01	493.21
			493.02	493.2
			493.1
10.2	Hypertension	3	401.1	402	402.11
			405.1	402.0	404.01
				403.00	404.11
				403.1
				405.0

With respect to the second criterion, Table 14 shows the minimum number of CLIs with required ICD.9 codes in the more severe SOI classes. For each medical condition episode of care, the severity-of-illness assignment rule accesses this table and determines the number of CLIs with required ICD.9 codes. If the number of CLIs with required ICD.9 codes is not achieved, then the patient's condition-specific episode will remain in the less severe SOI class (e.g., SOI-1 class). For example, a patient's sinusitis episode will receive an SOI-2 rank only if the episode contains 6 or more CLIs (refer to Table 14) with the ICD.9 codes listed in the sinusitis SOI-2 column of Table 13. Otherwise, the sinusitis episode will receive an SOI-1 rank.

[0157]

TABLE 14
Number of CLIs with Required ICD.9 Codes in the More Severe
SOI Classes
Medical		Number of
Condition	Medical Condition	Severity	SOI-1	SOI-2	SOI-3
Number	Long Description	Classes	Class	Class	Class
5.2	Conjunctivitis	2	1	6	—
6.5	Otitis media	3	1	6	10
7.2	Sinusitis	2	1	6	—
9.11	Asthma	3	1	6	10
10.2	Hypertension	3	1	6	10

Step 210: Vertical Episode Merge Rule

[0158] Often the physiology of some medical conditions results in the manifestation of different symptoms. Depending on a patient's presenting symptoms, a physician may code a patient's diagnosis under different, but somewhat correlated medical conditions. Considering physician coding alone can result in episodes that are fragmented and don't give a full picture of care received for a medical condition. The Grouper function addresses this situation using a technique called the vertical episode merge rule.

[0159] For example, a physician may assign a patient to one of several cardiovascular disease-related medical conditions: ischemic heart disease, congestive heart failure, cardiac arrhythmia, hypertension, and other cardiovascular conditions. Likewise, presenting symptoms could result in a physician assigning a patient to one of several respiratory-related medical conditions: emphysema, chronic bronchitis, chronic obstructive pulmonary disease, asthma, and lower respiratory infections.

[0160] However, there usually is one underlying physiologic condition for a patient having several related medical conditions. To address this issue, physician panels were formulated to determine which of a patient's condition-specific episodes should be combined and when. The panels developed algorithms for combining related condition-specific episodes and assigning a patient to an overall medical condition episode based on the underlying most resource-intensive physiologic condition. Within each PMC Group, the panels listed medical conditions in ascending order of expected resource intensity level and physiologic progression of the condition or disease (from least resource intensive and physiologic progression to the most resource intensive and physiologic progression (refer to Table 10).

[0161] The vertical episode merge rule accesses Table 10 and merges a patient's condition-specific episodes in the same PMC Group. The episodes merge down the PMC Group medical condition list, always merging the patient's lesser resource intensity episodes into the most resource intensive medical condition episode. For example, assume a patient has episodes of ischemic heart disease, hypertension, and angina pectoris. Table 10 shows that ischemic heart disease is the more resource-intensive medical condition in PMC Group 10. Consequently, hypertension and angina pectoris are folded into the patient's ischemic heart disease episode. This indicates that remaining hypertension and angina pectoris episodes are derived from patients without ischemic heart disease.

[0162] Failure to consider a patient's underlying medical condition will distort the accuracy of a physician's efficiency measurement. For example, in the above patient, episodes would be generated for ischemic heart disease, hypertension, and angina pectoris even though the patient's angina and hypertension can be attributed to the underlying condition of ischemic heart disease. Consequently, utilization experience within the patient's ischemic heart disease episode would be understated. If the vertical episode merge rule did not exist for combining related condition-specific episodes, then a patient's medical condition utilization would be understated and a physician's practice pattern efficiency measure would be inaccurate.

[0163] The vertical episode merge rule considers how much time separates episodes in the same PMC Group. For Episode #2 to be considered for merge to a previously occurring Episode #1, a CLI from Episode #2 must either overlap Episode #1's duration time period or occur during the window period of Episode #1. In the vertical episode merge rule, any window period greater than 60 days is considered to be equal to 60 days. However, the embodiment recognizes that complete window period durations may exist.

[0164] FIG. 3 shows the vertical merge process for a patient's episodes of ischemic heart disease (10.13), angina pectoris (10.8), and hypertension (10.2). The episodes are merged together to form one episode of ischemic heart disease (10.13).

Step 220: Horizontal Episode Merge Rule

[0165] A patient may present with non-specific signs and symptoms before a more specific medical condition is diagnosed and treated. Non-specific medical conditions do not necessarily reflect a bodily system or organ system. Instead, they can reflect signs and symptoms such as abdominal pain, chest pain, dyspnea, spleenomegaly, non-specific exanthem, and jaundice. Table 15 presents sample non-specific medical conditions.

[0166] A patient's non-specific medical condition episodes need to be merged with the patient's more specific, resource-intensive medical condition episodes. Otherwise, a patient's specific medical condition utilization would be understated and a physician's practice pattern efficiency measure would be inaccurate. The Grouper function addresses this situation using a technique called the horizontal episode merge rule.

[0167] The Grouper function performs a horizontal episode merge when a non-specific medical condition episode overlaps a more specific medical condition episode. In order to be considered for horizontal episode merge, episodes must overlap so that they have service days in common. As illustrated in FIG. 4, the episode overlap may occur towards the beginning, middle, or end of the ongoing specific medical condition. Window periods between episodes are not considered for horizontal episode merges. However, the embodiment recognizes that window periods between episodes may exist.

[0168] The horizontal episode merge rule accesses Table 15 for each non-specific medical condition and merges the non-specific episodes into the more specific medical conditions in the PMC Group order defined in the table. The rule operates as follows. When a non-specific episode is identified, examine the Horizontal Episode Merge Order by PMC Group columns and attempt to merge the non-specific episode. The rule loops over each PMC Group in the defined precedence order, starting with the medical condition number stated in Table 15. The embodiment recognizes that the PMC Groups may change in order and number.

[0169] For example, for general presenting symptoms (36.15), the horizontal episode merge rule attempts to merge the patient's non-specific episode (36.15) with medical conditions in PMC Group 9 (Respiratory Conditions), beginning with lower respiratory diseases (Medical Condition 9.3) and moving down the list from 9.3 through 9.20. If no specific medical condition for the patient is found in PMC Group 9, then the rule loops over to find a medical condition in PMC Group 10 (Heart and Pulmonary Conditions), beginning with ventricular arrhythmias (Medical Condition 10.4). The rule moves down the medical condition list from 10.4 through 10.25. If no specific medical condition for the patient is found in PMC Group 10, then the rule loops over to find a medical condition in PMC Group 13 (Digestive System Conditions).

[0170] The process continues on until either the non-specific episode (36.15) is merged with a more specific episode, or the precedence ordered PMC Groups are exhausted, and no horizontal episode merge occurs. If no merge occurs, then the patient's non-specific episode (36.15) remains as general presenting symptoms.

[0171]

TABLE 15
Selected Non-Specific Medical Conditions
Medical		Horizontal Episode Merge Order by PMC Group
Condition	Medical Condition	(Condition Listed Indicates Start Point for Merge)
Number	Abbrev Description	1	2	3	4	5	6	7	8	9	10
2.1	Intestinal infections	3.1	20.5	—	—	—	—	—	—	—	—
2.2	Other bacteria diseases	3.1	9.10	21.3	20.1	2.12	13.19	35.1	23.3	24.5	10.14
36.1	Complication of surgery	21.3	31.17	33.5	32.5	10.4	11.8	14.1	35.1	12.1	24.5
36.15	General presenting symptoms	9.3	10.4	13.10	3.1	17.1	15.1	16.3	18.1	19.5	4.8
36.16	Non-specific exanthem	29.4	3.1	9.1	31.1	7.1	20.1	15.7	10.4	11.2	17.4
36.17	Abdominal pain	13.4	15.3	26.1	14.1	22.5	12.1	23.3	25.2	17.1	34.4
36.18	Dyspnea	9.1	10.14	3.1	7.2	8.1	4.8	21.3	31.17	34.4	—
36.19	Chest pain	10.4	9.10	3.1	21.3	34.4	30.8	31.17	30.2	—	—
36.20	Non-newborn jaundice	15.1	13.10	3.1	31.17	21.3	20.1	19.5	—	—	—
36.23	Spleenomegaly	20.1	21.3	3.1	31.17	19.5	—	—	—	—	—
36.24	Hepatomegaly	15.1	13.10	3.1	31.17	21.3	19.5	—	—	—	—

Step 230: Episode Treatment Stage Rule

[0172] Identifying different treatment stages, including initial, active, and follow-up treatment, is important in medical conditions such as the following: breast cancer, prostate cancer, colorectal cancer, acute myocardial infarction, and lymphoma.

[0173] The Grouper function is designed to separate initial, active, and follow-up treatment episodes using key episode identification markers, or triggers, for each applicable medical condition. Then, these episode types are separately examined to perform physician efficiency measurement.

[0174] Initial, active, and follow-up treatment stages are defined using breast cancer as an example. An initial breast cancer episode is one where the patient has a surgery for the cancer (e.g., lumpectomy, modified radial mastectomy). An active breast cancer episode is one where no surgery is present, but chemotherapy or radiation treatment is observed within the episode. Here, the patient underwent surgery in a previous study period, so no surgical event is found in the patient's current ongoing breast cancer episode. Instead, during the study period, the claims data shows that the patient is being treated with chemotherapy and/or radiation. The presence of these treatments defines an active breast cancer episode. The utilization pattern and charges are different for an active breast cancer patient as compared to an initial breast cancer patient. A follow-up breast cancer episode is one where no surgery, chemotherapy, or radiation treatment is present in the patient's episode of care. After initial and active treatments, physicians will continue to code for breast cancer over the future years of patient follow-up care.

[0175] In a given study period, physicians do not treat an equal distribution of each episode type (initial, active, and follow-up). Moreover, the episode types have different average charges. The group function correctly identifies treatment stages and examines them separately to ensure that physician efficiency scores accurately reflect the physician's practice.

[0176] Table 16 presents selected triggers descriptions and the applicable procedural codes (CPT-4, HCPCS, and UB92) for trigger formation. For instance, the mastectomy trigger consists of CPT-4 codes 19120-19272, whereby a trigger event of mastectomy may be formed if one or more CLIs in a patient's episode have CPT codes 19120-19272. Table 17 lists the selected triggers as they apply to several medical conditions that require treatment staging. The episode treatment stage rule accesses Table 16 and Table 17 and determines if the appropriate triggers exist to classify a patient's episode as initial, active, inactive, or follow-up.

[0177]

TABLE 16
Selected Triggers for Differentiating Initial/Active/Inactive, Active/Inactive,
Initial/Follow-Up, Active/Follow-up, and Initial/Active/Follow-up
Trigger
Number	Trigger Description	CPT-4 Codes	HCPCS Codes	UB92 Codes
5	Breast tissue expander	11960-11971
9	Mastectomy	19120-19272
10	Breast repair	19316-19499
16	Bone marrow transplant	38230-38241, 85120
17	Repair constricted aorta	33840-33855, 33619
20	Lymphadenectomy	38562-38564
21	Lymph node excision	38300-38559
26	Liver surgeries	47001-47136, 47380-47399
28	Exploratory laparotomy	49000
39	Sterotactic brain procedure	61720-61770
46	Emergency room visit	99281-99285, 90500-90560		981
47	Inpatient visit	99221-99239, 99251-99263,		987
		99291-99298, 99431-99440,
		90200-90292, 99160-99172
48	Chemotherapy drugs		J0640, J1020-J1040,	J1094, J1440
			J1100,
			J1710-J1720,
			J1830, J2320-J2322,
			J2920-J2930,
			J7505,
			J8530-J8610,
			Q0083
49	Chemotherapy administration	96400-96549		280, 289, 335
50	Radiation therapy	77261-77499		330-333, 342

[0178]

TABLE 17
Selected Trigger Applications for Medical Conditions: Initial/Active/Inactive,
Active/Inactive, Initial/Follow-Up, Active/Follow-up, and Initial/Active/Follow-up
	Aortic		Malignant neoplasm,
	Aneurysm	Lymphoma	breast
Trigger		Active	Follow-Up	Active	Inactive	Initial	Active	Follow-up
Number	Trigger Description	10.21	10.22	21.5	21.6	30.8	30.9	30.10
5	Breast tissue expander						Yes
9	Mastectomy					Yes
10	Breast repair						Yes
16	Bone marrow transplant			Yes		Yes
20	Lymphadenectomy			Yes		Yes
21	Lymph node excision			Yes		Yes
26	Liver surgeries			Yes
28	Exploratory laparotomy			Yes
39	Sterotactic brain procedure			Yes
46	Emergency room visit	Yes
47	Inpatient visit	Yes
48	Chemotherapy drugs			Yes			Yes
49	Chemotherapy administration			Yes			Yes
50	Radiation therapy			Yes			Yes

[0179] For example, a patient's malignant neoplasm of the breast episode may be classified as initial if the following trigger events are present: breast repair, bone marrow transplant, lymphadenectomy, or lymph node excision. A patient's malignant neoplasm of the breast may be classified as active if the following trigger events are present: breast tissue expander, breast repair, chemotherapy drugs, chemotherapy administration, or radiation therapy.

[0180] However, the rule also examines Table 18 to determine whether the triggers meet specific qualifying event criteria. If a trigger event does not meet one of the specified criteria in Table 18 for a medical condition, then the trigger event does not count. For instance, in order for a patient's malignant neoplasm of the breast to be classified as initial, the table shows that: (1) one of the trigger events identifying the episode as initial needs to be $150 or more; or (2) two or more trigger events need to be present in the episode.

[0181] If these criteria are not met for the episode to be assigned to the initial treatment stage, then the rule accesses the Table 18 to determine if the patient's episode of malignant neoplasm of the breast may be assigned to the active treatment stage. The active treatment stage is assigned if a specific trigger event has a claim line item (CLI) on three different days. If no specific trigger event has a CLI on three different days, then the patient's episode is classified as follow-up.

[0182]

TABLE 18
Qualifying Event Criteria for Triggers to Apply to Medical Conditions:
Initial/Active/Inactive, Active/Inactive, Initial/Follow-Up, Active/Follow-up, and
Initial/Active/Follow-up
Medical
Condition	Medical Condition
Number	Long Description	Criteria Examined	Qualifying Event
10.19	Aortic aneurysm, initial	Criterion 1, or	1 trigger procedure >$150
	Criterion 2, or	Need >2 different trigger proc
	Criterion 3	Any 1 trigger CLI on 3 different days
10.20	Aortic aneurysm, follow-up	Episode defaults to 10.20 if Criteria 1-3 above not achieved.
21.5	Lymphoma, active	Criterion 1, or	1 trigger procedure >$150
	Criterion 2, or	Need >2 different trigger proc
	Criterion 3	Any 1 trigger CLI on 3 different days
21.6	Lymphoma, inactive	Episode defaults to 21.6 if Criteria 1-3 above not achieved.
30.8	Malignant neoplam of breast, initial	Critierion 1, or	1 trigger procedure >$150
	Criterion 2, or	Need >2 different trigger proc.
	Criterion 3	Not applicable
	Episode defaults to 30.9 if Criteria 1-3 not achieved.
30.9	Malignant neoplasm of breast, active	Rule now examines if episode meets following criteria:
	Critierion 1, or	Any 1 trigger CLI on 3 different days
	Criterion 2, or	Not applicable
	Criterion 3	Not applicable
30.10	Malignant neoplasm of breast, follow-up	Episode defaults to 30.10 if Criteria 1-3 above not achieved.

Stage 240: Complex Condition Merge Rule

[0183] Certain medical conditions represent the combination of two or more medical conditions in the same PMC Group. For example, diabetes mellitus with multiple complications (17.6) is one such medical condition. The Grouper function initially formulates one or more of the following episodes of diabetes for a patient: 17.1 diabetes mellitus with no complications; 17.2 diabetes mellitus with ophthalmic manifestation; 17.3 diabetes mellitus with neurologic manifestation; 17.4 diabetes mellitus with circulatory manifestation; and 17.5 diabetes mellitus with renal manifestation.

[0184] The complex condition merge rule then examines all initially formed episodes of diabetes for a patient and determines whether the patient has any of the combinations listed in Table 19. For instance, if a patient has an episode of diabetes with no complications (17.1) and an episode of diabetes with ophthalmic manifestations (17.2), then both episodes will be merges into 17.2. The rule also accesses the table to form diabetes with multiple complications (17.6). This medical condition does not exist before the complex condition merge rule. Table 19 shows that a patient is placed into diabetes with multiple complications (17.6) if the patient has any combination of 17.2, 17.3, 17.4, and 17.5.

[0185] The final list of diabetes medical conditions is as follows: 17.1 diabetes mellitus with no complications; 17.2 diabetes mellitus with ophthalmic manifestation; 17.3 diabetes mellitus with neurologic manifestation; 17.4 diabetes mellitus with circulatory manifestation; 17.5 diabetes mellitus with renal manifestation; and 17.6 diabetes mellitus with multiple complications.

[0186]

TABLE 19
Complex Condition Merge for Diabetes Mellitus
Medical	Medical	Patients Episodes are Merged
Condition	Condition	And Placed into Highest
Number 1	Number 2	Resource Intensity Episode
17.1	17.2	17.2
17.1	17.3	17.3
17.1	17.4	17.4
17.1	17.5	17.5
—	Any combination	17.6
	of 17.2, 17.3,
	17.4 and 17.5

Step 250: Complication Episode Merge Rule

[0187] The Grouper function uses the complication episode merge rule to identify medical conditions as complicating factors to a patient's underlying medical condition being examined. Complicating factors are patient-specific episodes that are clinically determined to be related to the underlying disease.

[0188] For example, physicians' code up to 70% of an average diabetic's charges under the related complications to diabetes (e.g., neuropathies, circulatory, eye, renal) and not diabetes care. This is because physicians frequently code only for the specific condition that they are treating at the time, which is often not diabetes. Therefore, without considering and including complication episodes with the actual diabetes episode, patient severity-of-illness and physician efficiency differences may be attributed to incomplete episode charges and utilization.

[0189] Another example is human immunodeficiency virus (HIV) conditions where tracking related complications is important or up to 80% of an average HIV patient's charges and utilization may be under-reported. These complicating conditions include pneumonia, opportunistic infections (e.g., cryptococcosis, candidiasis), nerve conditions, eye conditions, blood disorders, and malignancies. The Grouper function includes related complications and links them to the underlying condition being examined.

[0190] A third example is maternity conditions where complications before birth and complications of delivery are important to track to single and multiple newborn deliveries. Otherwise, up to 50% of an average maternity patient's charges and utilization may be under-reported.

[0191] Using HIV conditions as an example for applying the complication episode merge rule, the Grouper function initially formulates the following underlying medical condition episode for a patient: 3.1 Asymptomatic HIV infection.

[0192] One or more medical conditions then are linked as complications to the underlying medical condition of asymptomatic HIV infection. This linkage may result in the underlying medical condition episode being upcoded to a more resource intensive medical condition to reflect the physiologic progression of the disease and/or the underlying medical condition episode being moved to a higher severity-of-illness (SOI) class.

[0193] Table 20 shows the medical Conditions linked to asymptomatic HIV infection (3.1) that will upcode the patient's episode to HIV with infectious complication (3.2). The rule accesses Table 20 to determine if any of the complication medical conditions are present for the patient. If yes, then the patient is upcoded to HIV with infectious complication (3.2). For all complication episodes, the charges and utilization are merged into the ongoing HIV with infectious complication episode.

[0194]

TABLE 20
Complication Medical Conditions Linked to the Underlying Medical Condition
of HIV Infection
				HIV with
Medical		Complication		Infect Comp (3.2)
Cond		Condition	Complication Condition	SOI	SOI	SOI
Number	Verbal Description	Number	Verbal Description	Class	Class	Class
3.2	HIV with infectious comp	2.5	Tuberculosis	1
		2.5	Tuberculosis		2
		2.5	Tuberculosis			3
		2.11	Cytomegalic inclusion dz	1
		2.16	Cryptococcosis	1
		2.17	Candidiasis	1
		2.17	Candidiasis		2
		2.17	Candidiasis		3
		2.18	Coccidioidomycosis	1
		2.18	Coccidioidomycosis		2
		2.18	Coccidioidomycosis			3
		2.19	Histoplasmosis	1
		2.19	Histoplasmosis		2
		2.19	Histoplasmosis			3
		2.20	Blastomycotic infection	1
		2.20	Blastomycotic infection		2
		2.23	Toxoplasmosis	1
		2.23	Toxoplasmosis		2
		2.23	Toxoplasmosis			3
		2.24	Pneumocystosis	1
		9.7	Pneumonia	1
		9.7	Pneumonia		2
		9.7	Pneumonia		3

[0195] The rule then examines the SOI class of the linked complication medical condition episode. For instance, Table 20 illustrates that toxoplasmosis episodes with SOI-1 rank will not move the patient's HIV with infectious complication episode to a higher SOI class. However, the table shows that toxoplasmosis episodes with SOI-2 rank will move the patient's HIV with infectious complication episode to the SOI-2 class.

[0196] After applying the complication episode merge rule, Table 21 shows that a patient with HIV infection may be placed into one of the following PMC Group 3 medical conditions and SOI classes.

[0197]

TABLE 21
Human Immunodeficiency Infection Medical Conditions
and SOI Classes After Linking of Complication Episodes
Medical
Condition	Medical Condition	Number of
Number	Long Description	Severity Classes
3	Human Immunodeficiency Infections
3.1	HIV infection with no complications	1
3.2	HIV infection with infectious complication	3
3.3	HIV infection with CNS involvement	3
3.4	HIV infection with malignancy	3
3.5	HIV infection with multiple complications	3

Step 260: Comorbidity Marker Rule

[0198] In an embodiment, the Grouper function also uses a comorbidity marker rule to identify medical conditions as comorbidities to a patient's medical condition being examined. A comorbidity is a concurrent resource-intensive medical condition that is not related to the underlying disease state. For example, breast cancer is considered a comorbid condition to diabetes.

[0199] With respect to comorbidities, the individual physician efficiency analysis may eliminate from analysis any patient episode with a linked comorbidity. If such episodes are not eliminated, unnecessary heterogeneity may remain within condition-specific episodes. This heterogeneity adds error to any evaluation of physician efficiency.

[0200] Table 22 presents selected comorbid medical conditions. As indicated in Table 22, for a comorbid medical condition to be tracked to a medical condition episode in question, the patient's comorbid medical condition episode needs to be of a certain SOI class and total charge amount. For example, Table 22 shows that a patient's seizure disorder needs to be of SOI-2 class and at least $2,500 to be linked to another medical condition as a comorbidity. It is to be understood that the medical conditions listed in Table 22 do not need to have qualifying events, such as a charge amount or SOI level.

[0201]

TABLE 22
Selected List of Medical Condition Comorbidities
to a Patient's Medical Condition Being Examined
			Min-
Medical		Minimum	imum
Condition	Medical Condition	Episode	SOI
Number	Long Description	Charges	Level
2.4	Septicemia	$3,500	1
2.5	Tuberculosis	$2,500	1
2.11	Cytomegalic inclusion disease	$3,500	1
3.4	HIV infection with malignancy	$1,500	1
3.5	HIV infection with multiple complications	$1,500	1
4.11	Inflammatory diseases of CNS	$3,500	1
4.19	Multiple sclerosis	$2,500	1
4.24	Malignant neoplasm of brain, initial care	$2,000	1
4.25	Malignant neoplasm of brain, active care	$2,000	1
9.13	Emphysema	$3,000	2
9.14	Chronic obstructive pulmonary disease	$4,000	1
9.15	Spontaneous pneumothorax	$2,500	1
9.19	Malignant neoplasm of bronchus and lung,	$3,000	1
	active
10.16	Congestive heart failure	$3,000	2
10.17	Cardiomyopathy	$3,000	2
10.21	Acute myocardial infarction, active	$3,500	1
10.22	Acute myocardial infarction, follow-up	$3,000	1
11.14	Cerebrovascular hemorrhage	$2,500	1
13.20	Crohn's disease	$3,000	2
13.27	Malignant neoplasm of stomach	$2,000	1
13.30	Malignant neoplasm of colon, initial	$3,500	1
15.10	Chronic liver disease	$2,500	2
15.11	Liver transplant	$2,000	1
15.14	Malignant neoplasm of pancreas	$2,000	1
17.5	Diabetes mellitus with renal manifestation	$3,750	1
17.6	Diabetes mellitus with multiple	$3,750	1
	complications
20.9	Malignant neoplasm of spleen	$2,000	1
29.27	Kaposi's sarcoma	$2,000	1
31.19	Rheumatoid arthritis	$3,000	2
34.31	Organic dementias	$3,000	2
34.32	Schizophrenia	$3,000	2

Step 270: Partial Episode Marker Rules

[0202] The Gouper function determines partial and complete episodes of care for both acute and chronic episodes. The user decides whether to include or exclude partial episodes of care from analysis using the parameter SWITCH_DROPPARTIAL in the RUN.INI file (refer to Table 6).

[0203] In an embodiment, the system of the present invention uses different analytical approaches to identify partial episodes for acute and chronic medical conditions, as described below.

[0204] With respect to acute conditions, the partial episode marker rule states that acute episodes must pass the tests defined in Table 23 for both the beginning and the end of the study period, or the episodes will be marked as partial. The maximum allowable duration for any acute condition is 180 days.

[0205]

TABLE 23
Partial Acute Episodes of Care
If the medical	Then the
condition window period is:	episode is marked as partial when it:
Study-Start Partial Episodes
(Episodes declared partial
because they may have begun before the start of the study period.)
Equal to or greater than 90 days	Begins within 30 days of the start
	of the study period
Less than 90 days	Begins closer than 33% of the
	window period from the
	start of the study period
Study-End Partial Episodes
(Episodes declared partial
because they may not be complete at the end of the study period.)
Equal to or greater than 120 days	Begins during the last quarter of the
	study period
Less than 120 days	The last CLI associated with the
	episode is closer than 33% of the
	window period to the end of the study
	period, unless the episode has been
	under way for 180 days

[0206] For acute conditions having a window period equal to or greater than 120 days, the last three months of the study period are used as a run-out interval to allow all incomplete acute episodes as of the beginning of the fourth quarter to end. Allowing for a run-out interval reduces the fragmentation of acute episodes and therefore increases the validity and reliability of treatment pattern results.

[0207] For acute conditions having a window period less than 120 days, the episode will be marked as partial if the last CLI associated with the episode is closer than 33% of the window period to the end of the study period. For example, upper respiratory infection (URI) has a window period of 60 days. Assume a patient's ongoing episode of URI has a CLI with a date of service of December 20, and the end of the study period is December 31. Then, this URI episode would be marked as partial because the episode's last CLI is less than 33% of the window period (or 20 days) to the end of the study period.

[0208] In an embodiment, all chronic medical condition episodes begin during the first half of the study period to be considered complete episodes of care. Chronic episodes beginning in the second half of the study period are treated as partial. In an embodiment, the duration for a chronic condition is 180 days for the physician efficiency analysis. However, chronic conditions may continue on indefinitely as recognized by the window period of 365 days (refer to Table 11 for chronic disease window periods of 365 days).

Step 6: Perform PATAN Output Process

[0209] The PATAN output process involves four main functions.

[0210] The first function is to eliminate episodes of care that have been marked for removal during the read in RUN.INI file step. These episodes include: (1) partial episodes of care; and (2) episodes marked with comorbidities. If these two types of episodes have not been marked for deletion, then the episodes will be presented in the PATAN output file.

[0211] The second function is to assign episodes to physicians using the episode assignment logic as defined by the parameter SWITCH_ASSIGNTHRESHOLD during the read RUN.INI file step. Generally, the user is interested in examining those episodes of care where the physician recommends treatment and follow-up services. Therefore, an assignment rule is included that allows the physician to be a key treatment provider, but also allows for the physician to refer to another specialist for ongoing treatment. This assignment rule specifies that when a physician incurs a given percent of charges in an episode of care, that episode is assigned to that physician.

[0212] For the physician efficiency analysis, an assignment value of 20% usually is employed, but the user can change the assignment rule from 1-100% using the parameter SWITCH_ASSIGNTHRESHOLD in the RUN.INI file (refer to Table 6).

[0213] Using this rule, all professional charges are added in each episode of care, including office visits, lab/path services, medical and surgical procedures, and diagnostic tests. These professional charges may occur on an office visit, clinic, hospital outpatient, hospital inpatient, or other professional setting basis (e.g., nursing home, halfway home, home visit professional charges). All facility charges and prescription drugs are excluded. However, in an embodiment, other services may be included from an episode of care for the physician assignment rule.

[0214] For example, consider an assignment rule equal to 20%. This means that when a physician has 20% or more of all professional charges, the episode is assigned to that physician. At the 20% level, this rule generally results in episodes being assigned to about 1.20 physicians (or up to 20% of episodes may be assigned to more than one physician). Chronic disease episodes (e.g., asthma) are assigned to more than one physician more often than acute episodes (e.g., acute bronchitis).

[0215] When an episode is not assigned to any physician using the 20% assignment rule, another rule is employed which assigns that episode to the physician who has the highest percent of professional charges within the episode. For example, using the 20% assignment rule, if no physician has 20% or more of the professional charges, and the physician who comes closest to meeting this rule has 17% of professional charges in the episode of interest, then the episode is assigned to this physician and no other.

[0216] The third function of the PATAN output process is to group CLIs in episodes into 11 major service categories and 21 sub-service categories. During the extract core claims data fields step, a BETOS code is assigned to each service on a CLI (e.g., CPT-4, HCPCS). The BETOS code assignment allows for CLIs to be grouped into one of 11 major service categories and 21 sub-service categories. Table 24 presents the type of service codes that match to each BETOS code. Then, the type of service codes are mapped to the 11 major service and 21 sub-service categories. Service and sub-service categories are formed during the PATAN output process.

[0217]

TABLE 24
Type of Service Codes and BETOS Codes
Type Of
Service Code
Used for	Service	Type of Service
Processing	Category	Code	BETOS Code
0	Other Medical	Unknown	—
	Services
1	Professional	Office Visit	M1x
	Visits
2	Professional	Hospital Visit	M2x
	Visits
3	Professional	ER Visit	M3
	Visits
4	Professional	Other Visit	M4x, M5x, M6
	Visits
5	Other Medical	Anesthesia	P0
	Services
6	Med/Surg	Procedure	P1x, P2x, P3x,
	Procedures		P4x, P5x, P6x
7	Other Medical	Radiation Therapy	P7A
	Services
8	Other Medical	Other Oncology	P7B
	Services
9	Med/Surg	Endoscopy	P8x
	Procedures
10	Other Medical	Dialysis Service	P9x
	Services
11	Diagnostic	Imaging	Ixx
	Tests
12	Other Medical	Venipuncture	T1A
	Services
13	Lab/Path	Lab Test	T1B, T1C, T1D,
			T1E, T1F, T1G,
			T1H
14	Diagnostic	Functional Tests	T2x
	Tests
15	Other Medical	Durable Medical	Dxx
	Services	Equipment/Supplies
16	Other Medical	Ambulance	O1A
	Services
17	Other Medical	Chiropractic	O1B
	Services
18	Other Medical	Enteral/Parenteral	O1C
	Services
19	Other Medical	Chemotherapy	O1D
	Services
20	Other Medical	Other Drugs	O1E
	Services
21	Other Medical	Vision/hearing/speech	O1F
	Services	Services
22	Other Medical	Immunization	O1G
	Services
23	Other Medical	Other NEC Services	Y1, Y2, Z1, Z2
	Services

[0218] The fourth function of the PATAN output process is to implement the maximum duration rule for episodes of care, which is 180 days.

[0219] For chronic conditions (e.g., diabetes, asthma, ischemic heart disease), an episode of care begins when a CLI is initially found during the study period that has a defined ICD.9 code that has been assigned to that medical condition. Then, chronic conditions may continue on indefinitely as recognized by the window period of 365 days. However, for the purposes of physician efficiency analysis, chronic conditions are considered to have a 180-day duration. Therefore, a chronic condition ends 180 days after identifying the first CLI with a diagnosis (defined ICD.9 code) for the specific chronic condition. The rule determines that the patient is present for 180 days during the study period after the first CLI with a diagnosis for the specific chronic condition.

[0220] For acute conditions (e.g., upper respiratory infections, otitis media, conjunctivitis), the maximum allowable duration for the physician efficiency analysis also is 180 days. The embodiment recognizes that this maximum allowable duration may be varied.

Step 7: Store PATAN Output File

[0221] The PATAN Output File is stored in episode of care identifier order (Field 1 in Table 25). Table 25 lists the fields present on the PATAN Output File.

[0222]

TABLE 25
Fields in the PATAN Output File
	Field
Field	Descriptive
Number	Name	Notes
(Section A) Non-Repeated Episode Fields
1	Episode ID	The unique episode ID for each medical condition
		treatment episode.
2	Medical	The medical condition internal ID number.
	Condition
	Number
3	SOI	Severity of Illness index, where 1 is the least
		severe and 3 is the most severe or difficult to treat
		as defined for the medical condition.
4	Episode	The duration of the medical condition treatment
	Duration	episode, in days.
5	Total	The total allowed charges for the treatment
	Episode	episode, in dollars.
	Charges
6	Professional	Total allowed charges claimed by professional
	Charges	(excludes Rx and facility) physicians.
7	Physician ID	Identifies each physician that had significant
		involvement in the treatment for the episode. If
		multiple physicians were significantly involved in
		treating the episode, multiple rows are output for
		the episode, one for each physician.
8	Physician	Identifies the specialty number associated with
	Specialty	the physician. Since the specialty is determined
		by the PROVSPEC module, this field contains the
		value 0 in the version of the output from PATAN.
9	Physician	Identifies the marketbasket number associated
	Market-	with the physician. Since the marketbasket is
	basket	determined by the PROVSPEC module, this field
		contains the value 0 in the version of the output
		from PATAN.
10	Physician	Identifies the aggregate grouping number
	Aggregate	associated with the physician. Since the aggregate
	Grouping	grouping number is determined by the
	Code	PROVSPEC module, this field contains the value
	Number	0 in the version of the output from PATAN.
11	[not valid for	This field is not valid for the commercial pop-
	commercial	ulation. Always contains the value 1.
	population]
12	Physician	The is the charge component amount of the
	Charges	Professional Charges field (see above referenced
		field) that is attributable to the physician
		identified by the Physician ID field (see above
		referenced field).
13	Patient Age	The age of the patient at the beginning of
		the study period.
(Section B) Repeated Episode Fields for Each Service Category
(11 times per row)
1	Service	Eleven fields that contain utilization data at
	Category	the service category level.
	Utilization
2	Service	Eleven fields, ten of which contain charges in
	Category	dollars at the service category level (field 9 is not
	Charges	used because the system of the present invention
		does not break out charge data for inpatient
		admits).
(Section C) Repeated Episode Fields for Each Sub-Service Category
(21 times per row)
1	Sub-Service	Twenty-one fields that contain utilization data at
	Category	the sub-service category level.
	Utilization
2	Sub-Service	Twenty-one fields, twenty of which contain
	Category	charges in dollars at the sub-service category level
	Charges	(field 14 is not used because the system of the
		present invention does not break out charge data
		for inpatient admits).

Step 8: Sort PATAN Output File by Provider ID: PROVSORT1

[0223] The PATAN Output File is sorted by the primary sort key of physician identifier. The secondary sort key is the episodes assigned to a physician.

Step 9: Read in Episode Assignments from PROVSORT1

[0224] The episode assignments by physician from PROVSORT1 are read into the physician specialty module (PROVSPEC). PROVSPEC completes several of the missing fields in the PATAN Output File (refer to Table 25): (1) physician specialty (Field 8); (2) physician marketbasket (Field 9); and (3) physician aggregate grouping code number (Field 10).

Step 10: Assign Specialty Type to Physician

[0225] The PROVSPEC module employs a rule to select the most appropriate physician specialty when a physician has more than one specialty type assigned in the physician provider file. This processing step is helpful in selecting a specialty type that is most reflective of the physician's actual practice during the study period.

[0226] The rule examines all episodes associated with a physician and assigns each episode to one of the 31 marketbasket specialty types (refer to Table 26). A marketbasket consists of the most common conditions treated by each physician specialty type. The term physician is used broadly, and includes other professionals delivering medical care services, such as chiropractors, acupuncturists, podiatrists, nurse practitioners, and physical therapists.